Consent For Treatment
I voluntarily consent to Vitality Urgent and Primary Care (VUPC) and consent to treatment by the nurse practitioner on duty and whomever they may designate as their assistant, associate, collaborating physician, and patient care staff to provide my care. Such care may include but is not limited to, diagnostic testing and the administration of medications considered advisable in my diagnosis, treatment, and course of care. I acknowledge that no guarantee can be made or has been made as to the results of treatments or examinations and I understand that all medical treatments contain inherent risks.
I am aware that the practice of medicine is not an exact science and I acknowledge that no guarantees have been made to me as to the results of my examination or treatment at VUPC. I acknowledge that treatment at VUPC intended to address specific episodic illnesses or injury and is not intended to substitute for comprehensive care in lieu of a primary care physician or other specialized physicians. In order to provide the best chance for successful treatment, I accept responsibility to follow the advice of my treating provider including compliance with medications, discharge instructions and reevaluation with follow up or referral to specialty care. I agree to seek care in an Emergency Department of a hospital if my condition substantially changes. I further agree to hold harmless the Medical providers and staff of VUPC if fail to comply with the above conditions.
Patients at VUPC will be treated regardless of race, color, age, national origin, disability or religion. Notwithstanding the above criteria, VUPC reserves the right to refuse care to any individual who may have an unpaid balance, exhibits rude or disruptive behavior or any other reason at the discretion of the physician on duty.
AUTHORIZATION TO RELEASE HEALTHCARE INFORMATION AND PAYMENT GUARANTEE
I, the undersigned, authorize the Vitality Urgent and Primary Care to submit claims to my insurance company. I authorize to use and disclosure of my personal information for the purposes of diagnosing or providing treatment to me, obtaining payments for my care, or for the purposes of conducting the health care operations of the practice. I also authorize Vitality Urgent and Primary Care to release any information required in the process of application for financial coverage for the services rendered. This authorization provides that the practice may release objective clinical information related to my diagnoses and treatment, which may be requested by my insurance company or its designated agents. If it is the case that my insurance company utilizes a managed care company, my therapist may need to discuss my treatment with a case manager. I understand that my confidentiality will be compromised in such a case. I realize that his/her doing so is a necessity in his effort to secure ongoing care.
I authorize said payments to be applied to any unpaid balance for which I am responsible. I understand that I am responsible for and will pay the portion of my bill not covered by insurance companies or third-party payers. I agree to pay the account in full upon receipt of my billing statement. If the balance due is referred to a collection agency or attorney, I understand there may be additional fees, interest, or expenses for which I will be responsible. It is our policy that any insurance co-pays and deductibles or any balance of a bill owed by those without insurance is due at the time of service.
If you have questions about this Notice, please contact Vitality Urgent and Primary Care administration for additional details.
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