CONSENT FOR TREATMENT

I voluntarily consent to medical care at Vitality Urgent Care and to treatment by the nurse practitioner on duty and whomever they may designate as their assistant, associate, 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 guarantees can be 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 Vitality Urgent Care. I acknowledge that treatment at Vitality Urgent Care is intended to address specific episodic illnesses or injuries and is not intended to substitute for comprehensive care by a primary care physician or other specialized physicians. 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 Vitality Urgent Care if I fail to comply with the above conditions.

AUTHORIZATION TO RELEASE HEALTHCARE INFORMATION

I, the undersigned, authorize b to submit claims to my insurance company. I authorize the 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 healthcare operations of the practice. I also authorize Vitality Urgent 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.

CONSENT TO NON-SECURE ELECTRONIC COMMUNICATION

Standard email communication (Gmail, Yahoo, etc.), Skype, and Facetime are convenient ways to communicate with healthcare providers, and texting is a quick way to communicate short and more time-sensitive messages. These methods are non-encrypted and therefore not considered fully secure, and do not meet the security requirements set forth by the Health Insurance Portability and Accountability Act (HIPAA).

Phone and Fax are considered more secure, and the Tebra Portal (patient-facing side of our Electronic Health Record) can be used to e-message Vitality Urgent Care securely. I am aware that I can request access to Patient Fusion for the purposes of secure messaging. However, due to their convenience and wide availability, these non-secure methods are offered as an additional means of communicating with Vitality Urgent Care.

I, the undersigned, have read and understood the above, and consent to non-secure electronic communication. I release Vitality Urgent Care from any and all liability that may arise from the use of non-secure communication. If at any time in the future I wish to revoke this consent, I will inform Vitality Urgent Care by fax or by secure message via Patient Portal. This revocation will not be retroactive and will only affect communication going forward from the date of such revocation.