Family Registration Form

Family Registration Form

Effective 1/1/2026
Child 1:
Name*

First NameLast Name
Date of birth

MonthDayYear
Date
Gender at birth

MaleFemale
Patient's cellphone number:
Leave blank if the patient does not have a cell phone.
Insurance:
Insurance Company name:
Insurance Member ID number:
Insurance Group Number:
- Child 2:
- Name
  
  First NameLast Name
- Date of birth
  
  MonthDayYear
  Date
- Gender at birth
  
  MaleFemale
- Patient's cellphone number:
  Leave blank if the patient does not have a cell phone.
- Insurance:
- Insurance Company name:
- Insurance Member ID number:
- Insurance Group Number:
- Child 3:
- Name
  
  First NameLast Name
- Date of birth
  
  MonthDayYear
  Date
- Gender at birth
  
  MaleFemale
- Patient's cellphone number:
  Leave blank if the patient does not have a cell phone.
- Insurance:
- Insurance Company name:
- Insurance Member ID number:
- Insurance Group Number:
- Child 4:
- Name
  
  First NameLast Name
- Date of birth
  
  MonthDayYear
  Date
- Gender at birth
  
  MaleFemale
- Patient's cellphone number:
  Leave blank if the patient does not have a cell phone.
- Insurance:
- Insurance Company name:
- Insurance Member ID number:
- Insurance Group Number:

Parent/Legal Guardian #1:
Name*

First NameLast Name
Relationship to patient:*
Date of birth*

MonthDayYear
Date
Phone Number*
Please enter a valid phone number.
Email
example@example.com
Lives with patient(s):*

YesNo
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Parent/Legal Guardian #2:
Name

First NameLast Name
Relationship to patient:
Date of birth

MonthDayYear
Date
Phone Number
Please enter a valid phone number.
Email
example@example.com
Lives with patient:

YesNo
Address (enter "same" if same as above)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Additional Contact Questions:
If parents are divorced, separated or unmarried, please fill out this section:
Who has custody?
Are there any legal restrictions that would restrict the non-custodial guardian from consenting to medical treatment for the child(ren) or from obtaining information about the child(ren)'s medical treatment?

YesNo
If yes, please explain and clarify who should have access to medical records:
Please continue form below.

Consent to Treat Minor:

I hereby give consent to My 1st Clinic or to a covering provider to render any medical care necessary to my child. I understand that this authorization is given in advance of any specific diagnosis, treatment, or hospital care being required. This consent is given to any and all such diagnoses and treatments which a licensed provider at My 1st Clinic recommends. This authorization will remain in effect until revoked in writing by the parent or legal guardian.
Parent/Guardian: *

First NameLast Name
Signature:*

Clear
Date:*

MonthDayYear
Date
If above named guardians are unavailable:

I authorize in advance that care may be rendered in my absence with the people listed below (these may also be contacted in case of emergency):
1. Name:

First NameLast Name
Relationship:
2. Name:

First NameLast Name
Relationship:
3. Name

First NameLast Name
Relationship:
Please list any restrictions to the above statement:
Signature*

Clear
Date*

MonthDayYear
Date

Acknowledgement of Notice of Privacy Practices:
Please click here to review our standard Notice of Privacy Practices.
I acknowledge that I have been provided access to My 1st Clinic’s Notice of Privacy Practices (link above). I understand my rights regarding my child’s health information and consent to its use and disclosure for treatment, payment, and clinic operations as described in the notice
Name of parent/guardian:*

First NameLast Name
Signature*

Clear
Date*

MonthDayYear
Date
Relationship to patient:*

Medical Board of California Notice to Patients:

Medical doctors are licensed and regulated by the Medical Board of California.To check up on a license orto file a complaint go towww.mbc.ca.gov,email: licensecheck@mbc.ca.gov,or call (800) 633-2322
Patient:*

First NameLast Name
Parent/Guardian:*

First NameLast Name
Relationship to patient:*
Today's Date:*

MonthDayYear
Date
Signature*

Clear

Financial Policy (Effective January 1, 2026)
Thank you for choosing My 1st Clinic as your child’s health care provider. The following is a copy of our financial policy. Patient care is not permitted without the written consent of receipt and acknowledgement of the understanding of this policy.

1. Insurance & Billing
- Verification: It is the account holder's responsibility to verify with your insurance carrier that our clinic is in network with your insurance plan. Please provide a current insurance card and driver’s license at every visit.
- Account Changes: Please notify us immediately of any changes to your insurance, copay amounts, or mailing address.
- HMO Requirements: If you have an HMO, Dr. Reut Pagi must be assigned as the Primary Care Physician (PCP) prior to your visit, or the appointment will be rescheduled.
- Well-Visit Billing: While routine checkups are typically considered well-child visits, they often include assessments beyond the scope of insurance coverage for preventive care . While we generally do not collect copays for well-child visits, it's important to note that depending on how your insurance company processes the claim, you may be responsible for copays, deductibles, or other out-of-pocket costs after your visit. In addition, if a non-preventive issue is addressed during a well visit, it will be billed accordingly and your insurer may apply a copay, deductible, or other out-of-pocket cost for which you will be responsible.
- Medi-Cal as Secondary Insurance: We do not participate with Medi-Cal. Any patient responsibility determined by the primary insurance will be the responsibility of the account holder.
2. Payment Terms & Fees
- Standard Payments: Copays are due on the date of service. Balances are due upon receipt of the first billing statement. If an account has an open balance at the time of visit, the balance must be paid prior to the visit. We accept cash, check, debit, and all major credit cards. A $30 fee will be charged for any checks returned for insufficient funds. Accounts unpaid after 120 days will be sent to collections, and care for all family members will be discontinued.
- Self-Pay: If you do not have insurance and/or choose to proceed with self-pay, payment is expected at the time of service. A Good Faith Estimate will be provided upon request. We offer a 20% discount for all self-pay services paid in full on the day of the visit.
- Missed Appointments: We require 24-hour notice for cancellations. Missed appointments or late arrivals (10+ minutes) result in a $75 charge . Accumulating 3 missed appointments may result in dismissal from the clinic.
- After-Hours/Holidays: For urgent medical concerns outside of regular office hours, you may contact our after-hours service. A $45 charge applies for medical recommendations provided after hours.
- Form Fees: If parents request forms (e.g., school, camp, or sports physical forms) to be completed outside of a scheduled appointment, there will be a $35 fee per form. Please allow 3-5 business days for completion.
3. Credit Card on File (CCOF) & Auto-Pay
- Requirement: A valid Credit Card on File (CCOF) is required to receive care at My 1st Clinic.
- Billing & Auto-Charge: Your total account balance—which may include "patient responsibility" amounts determined by your insurance (EOB), urgent after-hours call fees, missed visit fees, and form fees—will be automatically charged to the credit card on file at the end of each month.
- Notifications: The account holder will receive a text in the middle of the month stating that there is an outstanding balance. Balance may be checked on the patient portal or through the insurance portal (EOB). If you have any questions regarding the balance, you must contact our billing department at (866) 371-6118 or your insurance carrier before the end of the month to resolve the inquiry prior to the auto-charge.
- Dispute/Privacy Waiver: In the event of a credit card chargeback or billing dispute, you provide consent for My 1st Clinic to release necessary protected health information (including, but not limited to, your Explanation of Benefits) to the merchant bank or credit card company to contest the dispute.
- Installments: Please notify the office in advance if you wish to arrange an installment plan.
4. Domestic & Custodial Arrangements:
- We do not mediate financial disputes between divorced/separated parents. The parent signing below is responsible for all payments regardless of custody agreements.
Authorization: I have read and understand the above financial policy. I authorize My 1st Clinic to keep my credit card on file and charge unpaid balances according to these terms.

This above policy applies to all current and future children listed under your account who receive care at our clinic.
Name of parent/guardian: *

First NameLast Name
Signature*

Clear
Date*

MonthDayYear
Date

Screening and Procedures Waiver
We pride ourselves on providing only the highest quality care for your child and do this by following many of the American Academy of Pediatrics and Bright Futures clinical guidelines on hearing and vision screens, behavior health screens, and labs.

However, some insurers do not cover services related to meeting these clinical recommendations. In fact, insurance company rules and policies change all the time. As prompt and appropriate treatment of your child is of primary importance to us, we ask that you sign a ‘waiver’ giving us permission to perform screenings, tests and non-covered services as we, your trusted providers of care, deem necessary.

Following is a list of the most frequently provided services for which we request a signed waiver and that you can use to determine coverage with your insurer. If you wish to opt out of any of the following, please let us know at the start of your visit. Please consider that declining screening may lead to delays in diagnosis.

Vision Screen via Computerized Photoscreen (CPT code 99177/99174):

Combines visual acuity testing and Visual Evoked Potential testing (or VEP). VEP is an important test for early detection of eye and vision problems in infants and young children. Amblyopia (or ‘lazy eye’) occurs when the brain does not receive proper images from the eye. If it is not diagnosed in early childhood, there may be a permanent loss of vision in the affected eye.

Hearing Screen (CPT code 92552)

Hearing screens should be performed every year and is also required for most preschools, public and private schools, and for sports. Lack of timely diagnosis of hearing impairment can lead to speech and developmental delays.

Developmental Testing (various CPT codes)

Developmental screening (including standard pediatric developmental screening done at well-visits, Edinburgh postpartum depression screening, child depression and anxiety screening, etc) are very important in the assessment of any development delays or potential problems. These screenings often lead to diagnoses that can be treated to assist development and mental health.

In-office lab tests

Often, patients want to know as soon as possible if their child has the flu, strep, covid, mono etc. We can effectively and efficiently determine that by performing in-office testing. Some insurers do not pay for in-office testing because they have contracts with external labs to provide these services. However, sending tests out to external labs can result in waiting days for results that we can provide to you much more quickly (usually within minutes). We believe it is important to treat your child as quickly as possible, and therefore offer these services in-office.
I acknowledge receipt of the waiver and have been informed of, and hereby attest that I fully understand my financial responsibility for any balance resulting from non-covered services, or services not covered in-office, by my insurer. I agree to pay the amount of the charge, in the event that my insurer does not pay for these services in full.
Name of parent/guardian:*

First NameLast Name
Signature*

Clear
Date*

MonthDayYear
Date
Should be Empty:

Family Registration Form

Child 1:

Insurance:

Child 2:

Insurance:

Child 3:

Insurance:

Child 4:

Insurance:

Parent/Legal Guardian #1:

Parent/Legal Guardian #2:

Additional Contact Questions:

If parents are divorced, separated or unmarried, please fill out this section:

Please continue form below.

Consent to Treat Minor:

If above named guardians are unavailable:

Acknowledgement of Notice of Privacy Practices:

I acknowledge that I have been provided access to My 1st Clinic’s Notice of Privacy Practices (link above). I understand my rights regarding my child’s health information and consent to its use and disclosure for treatment, payment, and clinic operations as described in the notice

Medical Board of California Notice to Patients:

Financial Policy (Effective January 1, 2026)

Authorization: I have read and understand the above financial policy. I authorize My 1st Clinic to keep my credit card on file and charge unpaid balances according to these terms.

Screening and Procedures Waiver