top of page
Image by CDC

General Consent for Care and Treatment


TO THE PATIENT: You have the right, as a patient, to be informed about your condition and the recommended surgical, medical or diagnostic procedure to be used so that you may make the decision whether or not to undergo any suggested treatment or procedure after knowing the risks and hazards involved. At this point in your care, no specific treatment plan has been recommended.


This consent form is simply an effort to obtain your permission to perform the evaluation necessary to identify the appropriate treatment and/or procedure for any identified condition(s). This consent provides us with your permission to perform reasonable and necessary medical examinations, testing and treatment.


By indicating "I agree" in the checkbox in the scheduling tool, you are indicating that (1) you intend that this consent is continuing in nature even after a specific diagnosis has been made and treatment recommended; and (2) you consent to treatment at this office. The consent will remain fully effective until it is revoked in writing.


You have the right at any time to discontinue services. You have the right to discuss the treatment plan with your physician about the purpose, potential risks, and benefits of any test ordered for you. If you have any concerns regarding any test or treatment recommended by your health care provider, we encourage you to ask questions.


By indicating in the checkbox, you acknowledge that you voluntarily request a physician, and/or mid-level provider (Nurse Practitioner, Physician Assistant, or Clinical Nurse Specialist), and other health care providers or the designees as deemed necessary, to perform reasonable and necessary medical examination, testing and treatment for the condition which has brought you to seek care at this practice. You understand that if additional testing, invasive or interventional procedures are recommended, you will be asked to read and sign additional consent forms prior to the test(s) or procedure(s).


This Informed Consent for Telehealth contains important information focusing on providing healthcare services using the phone or the Internet. Please read this carefully, and let us know if you have any questions. When you sign this document, it will represent an agreement between you, the people you are signing on behalf of, and Downers Grove Immediate Care.


Benefits and Risks of Telehealth refers to providing services remotely using telecommunications technologies, such as video conferencing, Doxy, or telephone. One of the benefits of telehealth is that the patient and clinician can engage in services without being in the same physical location. This can be helpful particularly during the Coronavirus (COVID-19) pandemic in ensuring continuity of care as the patient and clinician likely are in different locations or are otherwise unable to continue to meet in person. It is also more convenient and takes less time.


Telehealth, however, requires technical competence on both our parts to be helpful. Although there are benefits of telehealth, there are some differences between in-person treatment and telehealth, as well as some risks. For example:


  • Risks to confidentiality: As telehealth sessions take place outside of the medical office, there is potential for other people to overhear sessions if you are not in a private place during the session. Downers Grove Immediate Care will take reasonable steps to ensure your privacy. It is important; however, for you to make sure you find a private place for the session where you will not be interrupted. It is also important for you to protect the privacy of the session on your cell phone or other device. You should participate in therapy only while in a room or area where other people are not present and cannot overhear the conversation. 

  • Issues related to technology: There are many ways that technology issues might impact telehealth. For example, technology may stop working during a session, other people might be able to get access to a private conversation, or stored data could be accessed by unauthorized people or companies. 

  • Crisis management and intervention: Usually, Downers Grove Immediate Care will not engage in telehealth with clients who are currently in a crisis situation requiring high levels of support and intervention. We may not have an option of in-person services presently, but in a crisis situation, you may require a higher level of services. Before engaging in telehealth, we will develop an emergency response plan to address potential crisis situations that may arise during the course of our telehealth work.

  • Electronic Communications: You may have to have certain computer or cell phone systems to use telehealth services. You are solely responsible for any cost to you to obtain any necessary equipment, accessories, or software to take part in telehealth.

Fees: The same fee rates will apply for telehealth as apply for in-person therapy. Some insurers are waiving co-pays during this time. It is important that you contact your insurer to determine if there are applicable co-pays or fees which you are responsible for. Insurance or other managed care providers may not cover sessions that are conducted via telecommunication. If your insurance, HMO, third-party payor, or other managed care provider does not cover electronic therapy sessions, you will be solely responsible for the entire fee of the session. Please contact your insurance company prior to our engaging in telehealth sessions in order to determine whether these sessions will be covered. If there is a technological failure and we are unable to resume the connection, you will only be charged the prorated amount of actual session time.

Records: The telehealth sessions shall not be recorded in any way unless agreed to in writing by mutual consent. Downers Grove Immediate Care will maintain a record of session in the same way we maintain records of in-person sessions in accordance with policies.

Informed Consent: This agreement is intended as a supplement to the general informed consent and does not amend any of the terms of that agreement. Your signature below or electronic agreement indicates agreement with its terms and conditions.

Financial Policies 

Thank you for choosing Downers Grove Immediate Care. We are committed to providing you with high quality and affordable health care. The following is our financial policy. Please ask us any questions you may have, and then indicate in the only form of your acceptance. You may access this financial policy at any time by visiting our website.


Patient Identity Verification: In order to protect your identity and private health information, please be prepared to show photo identification (driver’s license or other photo identification) when you check in for each visit.


Insurance Billing: We submit claims to your insurance carrier on your behalf for the medical services that we provide to you based on the insurance information that you provide to us. We accept many insurance plans, but cannot guarantee their coverage of our services. You are responsible for verifying the coverage and benefits of your individual policy. Please contact your insurance company with any questions you may have regarding your coverage. We will verify your insurance policy eligibility and basic demographics at each visit, and you are responsible to have current insurance card(s) available when you arrive for your visit.


  • Insurance cards must be presented at check-in or completed using our text / email message platform.

  • All co-payments and deductibles must be paid at the time of service. This arrangement is part of your contract with your insurance company. Failure on our part to collect co-payments and deductibles from patients may be considered fraud by your insurance company. Please help us in upholding the law by paying your co-payment at each visit. We will not bill you for co-payments.


  • We do not submit claims to third party insurance companies. This includes motor vehicle insurance and corporate or personal liability insurance companies. You are responsible for payment at the time of service. A deposit may be asked from you and must be paid at check in and the balance will be paid when you check out. We will provide you with a statement within 20 business days that you may submit to those companies for reimbursement.


  • Workers Compensation accounts will be submitted for the patient, but in the event there is litigation to settle the case, the balance is due and payable by the patient after ninety (90) days from filing. If you do not have your current insurance card(s) with you at the time of your visit, you will be identified in our billing system as a “Self Pay” patient and the “self pay” policy outlined below (minus the 10% discount) will apply. You will be responsible for the bill at the time of service. Because we submit claims to insurance within 5 business days, it is important that you provide a picture of the front and back of your card(s) on the day of your visit or by using the online check in platform.


Patients With No Insurance (“Self Pay”): You are responsible for payment at the time of service. A deposit may be required from you prior to your appointment and must be paid at check in and any remaining balance will be paid when you check out. Uninsured patients may receive a “same-day-discount” if the bill is paid in full on the day of service. This discount is 10% off charges for the office visit (excluding labs, X-rays and any supplies). Without knowing the exact care that will be provided prior to the actual visit, the final discount amount is determined and paid at the completion of the visit.


Past Due Accounts: Balances due are to be paid in full within 30 days of the first statement, unless you set up an acceptable payment arrangement with Downers Grove Immediate Care at the time of your visit. All payment arrangements are designed to have your account paid in full within 90 days from the date of service. Interest will accrue on all unpaid balances at a rate of 10% per month beginning 30 days from your first statement. If your account is over 90 days past due, you will receive a letter stating that you have 10 days to pay your account in full.


Partial payments will not be accepted unless otherwise negotiated. Please be aware that if a balance remains unpaid, we may refer your account to a collection agency and you and your immediate family members may be discharged from this practice. If you (or a member of your immediate family) is sent to collections, a payment of $100.00 will be required prior to making an appointment in order to re-establish your account. This fee of $100.00 must be paid prior to each subsequent visit for the duration of 1 year.


Payment Methods: For your convenience, we have a number of payment methods available to you:

  • Cash, Check, Credit/Debit Card, HAS/FSA Card

  • Online Bill Pay is available on our website:


Monthly Statement: Every patient has their own account, regardless of age of the patient. The guarantor (also known as head of household) of a minor child will receive the monthly statement for that minor child. Thus, a family may receive more than one monthly statement based on the number of family members with an open balance on their particular account. Statements are only generated once the account has been processed by insurance, or after payment arrangements have been made at the time of service for uninsured accounts. If you are making one payment for more than one patient’s account, it is your responsibility to include the account number for each member you are paying on, along with the dollar amount you want paid on each account. Please understand that we post payments to the oldest owing patient encounter first.


NSF/Returned Checks: There is a fee (currently $40.00) for any check returned by the bank. This will be billed to you and cannot be billed to your insurance.


Annual Wellness Visits: The providers at Downers Grove Immediate Care participate with multiple insurance plans. Please keep in mind that health insurance policies are an agreement between the patient and the insurance company. The patient is responsible for the portion of the bill not covered by insurance. Unfortunately, not all insurance plans cover all services. If your insurance plan determines that a service is not covered, you will be responsible for the complete charge. Generally, insurance companies pay the majority of the fees for wellness visits, but there are portions of the visit (such as certain labs) that may not be covered. Also, if during your wellness visit you discuss with your provider more than is deemed a wellness visit by your insurance, you may be charged an additional office visit and you will be responsible for the payment. Again, because of the variety of insurance plans, we cannot guarantee your eligibility and coverage. It is your responsibility to check with your insurer to verify which services will be covered before your appointment, or if you have any other questions regarding your coverage.



By printing and signing below or electronically consenting,


  • You certify that you have read and fully understand the above statements and consent fully and voluntarily to its contents.

  • You have been provided the opportunity to review the clinic’s HIPAA privacy statement.

  • You have read and agree to abide by Downers Grove Immediate Care’s Financial Policies.

Patient Consent and Financial Policy (Read Below)
bottom of page