"Virtual Clinic" means that you may be evaluated and treated by a health care provider associated with Arti Pediatrics, Inc. from a distant location via electronic communication. Since this may be different than in-office consultation which you are familiar, it is important you understand and agree to the following statements:

• The consulting health care provider will be at a different location from patient.
• Additional medical or registration personnel may also be present in the room with the Provider.
• I understand that my voice and image may be recorded in order to assist the medical or registration personnel and I consent to any such audio and video recording.
• I understand there are potential risks to this technology, including, but not limited to, interruptions, unauthorized access, technical difficulties, and call termination. I understand there are alternatives and limitations to this type of care. I understand that my health care provider or I can discontinue the telemedicine consultation/visit if it is felt that the videoconferencing connections are not adequate for my
  situation.
• I understand that I may be released before all my medical problems are known or treated and it is my responsibility to make such conditions
  or symptoms known to the medical personnel as well as to make arrangements for follow-up care.
• Scope of virtual clinic is limited as only certain kind of patient problems can be addressed with limited physical exam. If it is determined during virtual clinic consultation that patient needs further evaluation then patient may be advised for in-office, urgent care or emergency room visit.
• Arti Pediatrics uses secure 3rd party tele-communication system. Though they are secure, Arti Pediatrics takes no liability for 3rd party security breach of information.

Authorizations

• The undersigned patient, or authorized individual acting on behalf of the patient, understands and agrees as follows: By agreeing, I am granting permission to all physicians and any other professionals to perform and administer care and treatment of the patient, or designated other qualified health care provider for such services.
• Grants permission to release to third party payor(s), private insurance company, their representatives and/or physician(s) involved in the patient's care, any information needed in connection with all care rendered to patient.
• If the patient is under the age of 18 or lacks capacity, the signing party affirms that they are either the parent or legal guardian of such patient
  and has full legal authority to seek medical assistance on behalf of the patient.

Financial Responsibility

I and/or my insurance carrier(s) agree to pay, in a timely manner, for health care services provided. I authorize payments directly to Arti Pediatrics, Inc. for all benefits payable. I understand that the private insurers may not include coverage for this service as a "Covered Service". I understand that I am responsible for any unpaid bills not covered by insurance company(s).

Notice of Privacy Policy

Arti Pediatrics Inc.

Dr. Arti Jain, MD
860 E. Remington Drive, Suite B
Sunnyvale, CA 94087

Your medical record may contain personal information about your health. This information may identify you and relate to your past, present or future physical or mental health condition and related health care services and is called Protected Health Information (PHI). We understand the importance of privacy and are committed to maintaining the confidentiality of your medical information. We make a record of the medical care we provide and may receive such records from others. We use these records to provide or enable other health care providers to provide quality medical care, to obtain payment for services provided to you as allowed by your health plan and to enable us to meet our professional and legal obligations to operate this medical practice properly. We are required by law to maintain the privacy of protected health information, to provide individuals with notice of our legal duties and privacy practices with respect to protected health information, and to notify affected individuals following a breach of unsecured protected health information. This notice describes how we may use and disclose your medical information. It also describes your rights and our legal obligations with respect to your medical information. We are required to abide by the terms of this Notice of Privacy Practices. We reserve the right to change the terms of our Notice of Privacy Practices at any time. Any new Notice of Privacy Practices will be effective for all PHI that we maintain at that time. If you have any questions about this Notice, please contact our Privacy Officer listed above.

Effective Date: August 8, 2014

This notice describes how medical information about you may be used and disclosed and how you can get access to this information. Please review this notice carefully.

The medical record is the property of this medical practice, but the information in the medical record belongs to you. The law permits us to use or disclose your health information for the following purposes:

For Care or Treatment: Your PHI may be used and disclosed to those who are involved in your care for the purpose of providing, coordinating, or managing your services. This includes consultation with clinical supervisors or other team members. Your authorization is required to disclose PHI to any other care provider not currently involved in your care. Example: If another physician referred you to us, we may contact that physician to discuss your care. Likewise, if we refer you to another physician, we may contact that physician to discuss your care or they may contact us.

For Payment: Your PHI may be used and disclosed to any parties that are involved in payment for care or treatment. If you pay for your care or treatment completely out of pocket with no use of any insurance, you may restrict the disclosure of your PHI for payment. Example: Your payer may require copies of your PHI during the course of a medical record request, chart audit or review.

• For Business Operations: We may use or disclose, as needed, your PHI in order to support our
  business activities including, but not limited to, quality assessment activities, employee review
  activities, licensing, and conducting or arranging for other business activities. We may also disclose PHI in the course of providing you with reminders about your child's appointments by leaving messages on your voicemail, sending text messages, or a message with whoever answers your phone about questions you asked or test results. Example: We may share your PHI with third parties that perform various business activities (e.g., Council on Accreditation or other regulatory or licensing bodies) provided we have a written contract with the business that requires it to safeguard the privacy of your PHI.

Required by Law: Under the law, we must make disclosures of your PHI available to you upon your request. In addition, we must make disclosures to the Secretary of the Department of Health and Human Services for the purpose of investigating or determining our compliance with the requirements of the Privacy Rule, if so required.

Without Authorization: Applicable law and ethical standards permit us to disclose information about you without your authorization only in a limited number of other situations. Examples of some of the types of uses and disclosures that may be made without your authorization are those that are:

• Required by Law, such as the mandatory reporting of child abuse or neglect or mandatory
  government agency audits or investigations (such as the health department)
• Required by Court Order
• Necessary to prevent or lessen a serious and imminent threat to the health or safety of a person or the public. If information is disclosed to prevent or lessen a serious threat it will be disclosed to a person or persons reasonably able to prevent or lessen the threat, including the target of the threat.

Verbal Permission:

1. We may use or disclose your information to family members that are directly involved in your
   receipt of services with your verbal permission.
2. Proof of Immunization. We will disclose proof of immunization to a school where the law requires the school to have such information prior to admitting a student if you have agreed to the disclosure on behalf of yourself or your dependent.

With Authorization: Uses and disclosures not specifically permitted by applicable law will be made only with your written authorization, which may be revoked. Your explicit authorization is required to release psychotherapy notes and PHI for the purposes of marketing, subsidized
treatment communication and for the sale of such information.

Your rights regarding your PHI

• You have the following rights regarding PHI we maintain about you. To exercise any of these rights, please submit your request in writing to our Privacy Officer:
• Right of Access to Inspect and Copy. You have the right, which may be restricted only in
  exceptional circumstances or with documents released to us, to inspect and copy PHI that
  maybe used to make decisions about service provided.
• Right to Amend. If you feel that the PHI we have about your child is incorrect or incomplete, you may ask us to amend the information although we are not required to agree to the amendment.
• Right to an Accounting of Disclosures. You have the right to request an accounting of certain of the disclosures that we make of your PHI. We may charge you a reasonable fee if you request more than one accounting in any 12-month period.
• Right to Request Restrictions. You have the right to request restrictions on certain uses and disclosures of your child's health information by a written request specifying what information you want to limit, and what limitations on our use or disclosure of that information you wish to have imposed. Example: You may request we not disclose information to your commercial health plan concerning health care items or services for which you paid for in full out-of-pocket. We reserve the right to accept or reject any requests and will notify you of our decision.
• Right to Request Confidential Communication. You have the right to request that we
  communicate with you about PHI matters in a specific manner (e.g. telephone, email, postal mail, etc.) We will comply with all reasonable requests submitted in writing which specify how or where you wish to receive these communications.
• Right to a Copy of this Notice. You have the right to a copy of this notice.

Website Privacy

Any personal information you provide us with via our website, including your e-mail address, will
never be sold or rented to any third party without your express permission. If you provide us with any personal or contact information in order to receive anything from us, we may collect and store that personal data. We do not automatically collect your personal e-mail address simply because you visit our site. In some instances, we may partner with a third party to provide services such as newsletters, surveys to improve our services, health or company updates, and in such case, we may need to provide your contact information to said third parties. This information, however, will only be provided to these third-party partners specifically for these communications, and the third party will not use your information for any other reason. While we may track the volume of visitors on specific pages of our website and download information from specific pages, these numbers are only used in aggregate and without any personal information. This demographic information may be shared with our partners, but it is not linked to any personal information that can identify you or any visitor to our site.

Our site may contain links to other outside websites. We cannot take responsibility for the privacy policies or practices of these sites and we encourage you to check the privacy practices of all internet sites you visit. While we make every effort to ensure that all the information provided on our website is correct and accurate, we make no warranty, express or implied, as to the accuracy, completeness or timeliness, of the information available on our site. We are not liable to anyone for any losses, claims or damages caused in whole or in part, by any of the information provided on our site. By using our website, you consent to the collection and use of personal information as detailed herein. Any changes to this Privacy Policy will be made public on this site so you will know what information we collect and how we use it.

Breaches: You will be notified immediately if we receive information that there has been a breach involving your PHI.

Complaints: If you believe we have violated your privacy rights, you have the right to file a complaint in writing with our Privacy Officer at Arti Pediatrics. If you have questions and would like additional information, you may contact us at 408-462-9261.

If you are not satisfied with the manner in which this office handles a complaint, you may submit a formal complaint to:

Region IX Office of Civil Rights

US Department of Health and Human Services

90 7lh St. Ste 4-100

San Francisco, CA 94103

Phone: (415) 437-8310

Voice: (415) 437-8329

Fax: OCRMail@hhs.gov

Travel Consultation Policy

Arti Pediatrics, Inc.

Arti Pediatrics offers Travel Consultations for patients travelling to certain high-risk countries. All services are provided by Dr. Jain. Vaccines are recommended by Dr. Jain and are administered by the doctor or medical assistant. For countries or situations with which Arti Pediatrics is not
familiar, we will refer you to a travel medicine clinic.

Arti Pediatrics Travel Consultations include:
Review of Centers for Disease Control (CDC) country-specific recommendations for your child's age group, destination, and purpose of travel. Malaria prevention, including medication prescription and counselling.

Vaccines: accelerating the routine vaccine schedule, administration of injectable Typhoid vaccine, prescription of oral Typhoid vaccine, as appropriate. List of Over the Counter (OTC) medications to take with you. Sun and mosquito protection recommendations.

Preparing for your child's travel consultation:

• Travel Consultations should be scheduled at least 6 weeks before departure. Typhoid and other vaccines are most effective if given at least 2-4 weeks before travel.
  It is important to have details of your itinerary so the doctor can make a thorough assessment of the health risks.
• Bring your child's immunization record (yellow card) to the appointment, as well as all prior travel-related vaccination records.
• The patient and guardian must be present at the appointment.

Billing: Contact your insurance carrier so you are aware of your coverage; the CPT codes for typical services are provided below.

• The Travel Consultation with the doctor will be billed as Preventive Counseling (CPT 99401, 99402, 99403, 99404). It cannot be billed as an office visit.
• The Preventive Counseling charge for each person will range from $75 to $100, depending on the length and complexity of the visit.
• Typhoid vaccine (injectable, CPT 90691) is $150, which includes the vaccine cost and administration fee.
• Prescription and counselling for the Oral Typhoid vaccine are included in the Preventive Counseling service.

Routine childhood vaccines will be billed to your insurance as usual.

Because most insurance companies do not cover travel consultations or Typhoid vaccines, you will be asked to pay for these services at the time of your visit. Arti Pediatrics will still bill your insurance and reimburse you if an insurance company does pay for the visit.
By signing below, I agree to be responsible for the full cost of the elective or travel vaccines given, and for any administration fees charged today. I understand that Arti Pediatric will bill my insurance company for the above vaccine(s). I understand that I will be reimbursed in full by
Arti Pediatrics only if payment is received from my insurance company.

Office and Financial Responsibility Policy May 2021

Arti Pediatrics, Inc.

CO-PAYMENT AND DEDUCTIBLE: The patient is responsible for their deductible and copayment. Insurance co-payment is always due at the scheduled time of service. If the patient’s
deductible has been satisfied, Arti Pediatrics will bill the patient’s health plan. If the patient’s
deductible has not been satisfied, Arti Pediatrics will collect 75% of our fees schedule at the
scheduled time of service. Arti Pediatrics will bill the insurance, and after the claim is processed,
either over-payment would be reimbursed or applied towards the patient’s next visit or underpayment would be billed to the patient.

INSURANCE CARD: If the patient forgets to bring their insurance card, they will be asked to
cover the service charges in the form of cash or check at the time of service. Arti Pediatrics will
be happy to bill the patient’s insurance if you provide us with a copy of the insurance card. A
refund will be issued to you when your health plan makes payments on your claim.

CHANGE OF INSURANCE: Any change to patient insurance, including change of patient address,
needs to be informed to Arti Pediatrics well in advance. Patient/patient's guardians is/are
required to pay upfront for the services rendered on that day if the new insurance information
is presented on the date of visit.

SECONDARY INSURANCE: If there is additional insurance (secondary insurance) which covers
the patient then insurance must be informed prior to date of service. Failure to do that may
result in payment reversal by insurance in future. If such thing happens then Arti Pediatrics
would apply the balance to the patient. This payment needs to be made immediately. It would be the patient’s responsibility to bill secondary insurance or other insurance.

IDENTIFICATION CARD: Arti Pediatrics needs to have a US government-issued identification
card on file. This can be a driver’s license, passport, or social security number.

NON-COVERED SERVICES: If Arti Pediatrics provides services to your child/children that are not
covered by your health plan, you will be held responsible for payment in full for those services.
Your signature below constitutes agreement to pay for such services. It is your responsibility to
know and understand your coverage no matter what type/form of plan you hold. Not all
services are a covered benefit in all contracts. Contact your insurance company to find out what
benefits are covered or excluded under your plan and which healthcare providers are within
your network.

APPOINTMENT CANCELLATION CHARGES: A partial appointment fee of $40.00 will be charged
for appointments cancelled without a minimum of 24 hours notification. In order to allow
sufficient time for your appointment, as well as for other patients, please arrive promptly for
your appointment time. Be aware that if you are more than 10 minutes late, we may need to
reschedule your appointment to another day. When the sibling's appointments are made
together then Arti Pediatrics need 72 hours of notification for cancellation of appointments else
$40.00 for each sibling will be charged.

AFTER-HOURS ADVICE: After-hours advice is available when the office is closed. This service is
only for urgent health concerns. Any non-urgent calls should be made during office hours. In
case of emergency please call 911 or go to the nearest emergency room. For any non-urgent
concerns Arti Pediatrics provides secure messaging via Patient Ally. After-hour appointments
are scheduled by special arrangements. There may be occasions when this service may not be
available, such as technology failure or physician(s) unavailability. In that case, please call 911
or go to the nearest emergency room.

AFTER-HOURS CHARGES: After hours/weekend/holiday care services provided, when an
individual physician or other health care professional is required to render the services outside
of regular posted office hours to treat a patient's urgent illness or condition in office or via
virtual visit. These services are provided that would otherwise require more costly urgent care
or emergency room settings. Arti Pediatrics WOULD NOT bill insurance for such services and
Arti Pediatrics would charge $40 upfront for rendering such services.

REFERRALS: When this office makes a sub-specialist, radiology, or lab referral for you, it is your
responsibility to verify if a physician or facility is participating in your insurance network as a
contracting provider and what benefits are covered under your plan, in order to obtain your
maximum benefits.

INSURANCE DISPUTES: Arti Pediatrics bills your insurance for the services. It may take a
significant amount of time for claims to be processed. In case the insurance denies or rejects all
or part of the service charges, those charges will be billed to the patient, and it is patient’s
responsibility to follow up with insurance and file for any reimbursement. One-time patients
(like travelling patients) are required to pay upfront. On patient request, Arti Pediatrics may bill
the insurance for those one-time patients and credit the patient on payment from insurance.

BILLING FOR YOUR NEWBORN: If the patient is a newborn, parents please make sure to add
your child to the insurance. This would expedite the billing for the services. If not done within
two weeks from the date of birth of the child, then Arti Pediatrics will bill the patient directly
and parents would need to file for reimbursement with insurance.

PAST DUE BALANCE FEE: Once your insurance company has made a payment, your portion will
be billed to you and is due within 30 days of the date of the statement. A fee of $20.00 will be
applied to any unpaid balance that exceeds 30 days past due. Your account may be turned over
to a collection agency if your unpaid account balance exceeds 90 days. Arti Pediatrics reserves
the right to not provide subsequent services unless the past due balance is paid.

IMMUNIZATION CARD REPLACEMENT: A charge of $10.00 for replacement cards.

SCHOOL AND OTHER FORM FEES: Arti Pediatrics charges fees for filling out school forms and
other forms. There is a separate fee for the urgent request. Please check with the office for the fees.

COLLECTIONS: If it is necessary to assign your account to a collection agency and/or an
attorney, you will be responsible for all associated fees and costs.

RETURNED CHECK FEE: For any returned check, Arti Pediatrics will charge a fee of $25, in
addition to the original amount of the check. This charge covers our bank fees as well as
additional processing and billing costs.

MEDICAL RECORDS: Arti Pediatrics requires a signed written request to copy a patient’s chart
and will provide copies within 15 days. There is a minimal processing fee of $20.00 that must be
collected prior to releasing the records.

SHARING RECORDS FOR TREATMENT: We share medical records with other health care providers to allow and promote continuity of care among providers.

VOICEMAIL AND TEXT NOTIFICATIONS: As a service to our patients, Arti Pediatrics provides courtesy appointment reminder calls/texts and possibly other important calls that may be placed. The information may include protected health information. By initialling below, you consent to receive such calls/texts at the phone number(s) you have provided to us.

ELECTRONIC PRESCRIPTIONS (E-Prescribing) And Online Access to Medical Records
I voluntarily authorize Arti Pediatrics to allow E-Prescribing for prescriptions, which allows health care providers to electronically transmit prescriptions to the pharmacy of my choice, review pharmacy benefit information and medication dispense history if a physician/patient relationship exists, or until I withdraw my consent. Arti Pediatrics uses Patient Ally as a patient portal to share and communicate with patients. You acknowledge that you accept those terms and conditions of Patient Ally, which can be found on the Patient Ally website.

PATIENT TERMINATION: Arti Pediatrics values its patient relationships, and it wants to protect
all patients’ rights. We will only terminate patient relationships with cause and after careful
consideration. Reasons for termination include Repeatedly not showing for scheduled
appointments, not complying with recommended medical care, being hostile or abusive to
staff, not trying or neglecting to pay your account in a timely manner.

Households
Please list all those living in the child’s home.

Birth History

During pregnancy, did mother

Have any family members had the following?

Does your child have, or has your child ever had,

(For girls) Problems with her periods