Notice of Privacy Practices for My 1st Clinic
Reut Ron Pagi, MD | 8500 Wilshire Blvd Ste 917, Beverly Hills 90211 |
(310) 789-2058 | info@my1stclinic.com

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

Your Rights: When it comes to your health information, you have certain rights. This section explains your rights and some of our responsibilities to help you.

●  Get an electronic or paper copy of your medical record: You can ask to see or get an electronic or paper copy of your medical record and other health information we have about you. We will provide a copy or summary of your health information, usually within 30 days or your request. We may charge a reasonable, cost-based fee.
●  Ask us to correct your medical record: You can ask us to correct health information about you that you think is incorrect or incomplete. We may say “no” to your request, but we’ll tell you why in writing within 60 days.
●  Request confidential communication: You can ask us to contact you in a specific way (for example, home or office phone) or to send mail to a different address. We will say “yes” to all reasonable requests.
●  Ask us to limit what we share: You can ask us not to use or share certain health information for treatment, payment, or our operations. We are not required to agree to your request, and we may say “no” if it would affect your care. If you pay for a service or health care item out-of-pocket in full, you can ask us not to share that information for the purpose of payment or our operations with your health insurer. We will say “yes” unless a law requires us to share that information.
●  Get a list of those with whom we have shared information: You can ask for a list (accounting) of the times we’ve shared your health information for six years prior to the date you ask, who we shared it with, and why. We will include all the disclosures except for those about treatment, payment, and health care operations, and certain other disclosures (such as any you asked us to make). We’ll provide one accounting a year for free but will charge a reasonable, cost-based fee if you ask for another one within 12 months.
●  Get a copy of this notice: You can ask for a paper copy of this notice at any time, even if you have agreed to receive the notice electronically. We will provide you with a paper copy promptly.
●  Choose someone to act for you: If you have given someone medical power of attorney or if someone is your legal guardian, that person can exercise your rights and make choices about your health information. We will make sure the person has this authority and can act for you before we take this action.
●  File a complaint if you feel your rights are violated: You can complain if you feel we have violated your rights by contacting us using the information on page 1. You can file a complaint with the U.S. Department of Health and Human Services Office for Civil Rights by sending a letter to 200 Independence Avenue, S.W., Washington, D.C. 20201, calling 1-877-696-6775, or visiting www.hhs.gov/ocr/privacy/hipaa/complaints/. We will not retaliate against you for filing a complaint.

Your Choices: For certain health information, you can tell us your choices about what we share. If you have a clear preference for how we share your information in the situations described below, talk to us. Tell us what you want us to do, and we will follow your instructions. 
● In these cases, you have both the right and choice to tell us to: Share information with your family, close friends, or others involved in your care; Share information in a disaster relief situation; Include your information in a hospital directory or contact you; Contact you for fundraising efforts.

If you are not able to tell us your preference, for example if you are unconscious, we may go ahead and share your information if we believe it is in your best interest. We may also share your information when needed to lessen a serious and imminent threat to health and safety.

● In these cases we never share your information unless you give us written permission: Marketing purposes; sales of your information; most sharing of psychotherapy notes.
● In the case of fundraising: we may contact you for fundraising efforts, but you can tell us not to contact you again.

Our Uses and Disclosures: We typically use or share your health information in the following ways.

●  Treat you: We can use your health information and share it with other professionals who are treating you. Ex. A doctor treating you for an injury asks another doctor about your overall health condition.
●  Run our organization: We can use and share your health information to run our practice, improve our care, and contact you when necessary. Ex. We use health information about you to manage your treatment and services.
●  Bill for your services: We can use and share your health information to bill and get payment from health plans or other entities. Ex. We give information about you to your health insurance plan so it will pay for your services.

How else can we use or share your health information: We are allowed to share your information in other ways-usually in ways that contribute to the public good, such as public health and research. We have to meet many conditions in the law before we can share your information for these purposes. For more information see: www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/index.html
●  Help with public health and safety issues: We can share health information about your for certain situations such as: preventing disease, helping with product recalls, reporting adverse reactions to medications, reporting suspected abuse, neglect, or domestic violence, and preventing or reducing a serious threat to anyone’s health or safety.
●  Do research: we can use or share your information for health research
●  Comply with the law: We will share information about you if state or federal laws require it, including with the Department of Health and Human Services if it wants to see that we’re complying with federal privacy law.
●  Respond to organ and tissue donation requests: We can share health information about you with organ procurement organizations.
●  Work with a medical examiner or funeral director: We can share health information with a coroner, medical examiner, or funeral director when an individual dies.
●  Address workers’ compensation, law enforcement, and other government requests: We can use or share health information about you: For workers compensation claims, for law enforcement purposes or with a law enforcement official, with health oversight agencies for activities authorized by law, and for special government functions such as military, national security, and presidential protective services.
●  Respond to lawsuits and legal actions: We can share health information about you in response to a court or administrative order, or in response to a subpoena.

Our Responsibilities: We are required by law to maintain the privacy and security of your protected health information. We will let you know promptly if a breach occurs that may have compromised the privacy or security of your information. We must follow the duties and privacy practices described in this notice and give you a copy of it. We will not use or share your information other than as described here unless you tell us we can in writing. If you tell us we can, you may change your mind at any time (please let us know in writing).

Changes to the Terms of this Notice: We can change the terms of this notice, and the changes will apply to all information we have about you. The new notice will be available upon request, in our office, and on our website www.my1stclinic.com .

Effective date of notice: 1/1/2025
Notice of Privacy Practices for My 1st Clinic

Medical doctors are licensed and regulated
by the Medical Board of California.

To check up on a license or
to file a complaint go to
www.mbc.ca.gov,
email: licensecheck@mbc.ca.gov,
or call (800) 633-2322

Thank you for choosing My 1st Clinic! The following is a copy of our financial policy. By signing below, you acknowledge and agree to the terms of this financial policy.

Insurance:

It is the account holder's responsibility to verify with your insurance carrier that our clinic is in network with your insurance plan. Please bring a current copy of your insurance card to every visit. A scanned copy of the assigned account holder’s current insurance card and driver’s license is required to be kept on file. Please present newly issued insurance cards upon scheduling an appointment.

If you have an HMO insurance plan, please assign Dr. Reut Pagi as your child’s primary care physician (PCP) prior to your visit. If we cannot confirm that Dr. Pagi is listed as your child’s PCP , we will ask that the appointment be rescheduled.

Please notify the office as soon as possible of any and all account changes, including co-pay amounts, insurance updates, and change of mailing address.

Our clinic bills insurance for virtual, sick, and preventive care visits. 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.

Medi-Cal as secondary insurance: My 1st Clinic does not participate with Medi-Cal. Any patient responsibility determined by the primary insurance will be the responsibility of the account holder.

Payments:

Copays are due on the date of service. Outstanding balances are due upon receipt of the first billing statement. If a patient has an open balance at the time of visit, the balance must be paid prior to the visit. Outstanding balances not paid within 120 days will be sent to our collection agency and may be reported to the major credit bureaus. Once an account has been sent to the collection agency, care in our office will be discontinued for all family members. My 1st Clinic accepts cash, personal check, debit cards, Visa, Mastercard, Discover, and American Express. A $30 fee will be charged for any checks returned for insufficient funds.

Self-Pay Accounts:

If you do not have insurance and/or choose to proceed with self-pay, payment is expected at the time of service. A price list of services is available upon request. We offer a 20% discount for all self-pay services paid in full on the day of the visit.

Credit Card on File/AutoPay:

In order to make sure that we can collect your portion of the bill once your insurance company processes the claim, we require that a valid credit card be kept on file with the practice. Your card will only be charged the outstanding amount that your insurance company determines to be ‘patient responsibility’, as spelled out in your Explanation Of Benefits (EOB). Once your card is charged, a receipt will be sent to you by email. If you would like to make arrangements to pay the amount by installments, please notify the office in advance.

Missed Appointments and Late Arrivals:

We kindly request a 24-hour notice for any appointment cancellations. Missed appointments and late cancellations (within 24 hours) will result in a $75 charge to your account.

To help us keep our office running on schedule, we ask that you arrive 15 minutes prior to your scheduled appointment time. If you arrive more than 10 minutes past your scheduled appointment time, your appointment may need to be rescheduled and a missed appointment fee will be applied.

If an account has accumulated 3 missed appointments or late arrivals, they may be subject to dismissal from the clinic and no further appointments will be scheduled.

After Hours/Holiday Care:

For urgent medical concerns outside of regular office hours, you may contact our after-hours service. Please note that a $45 charge to account holder responsibility will apply for after-hours recommendations. Many insurance plans have a 24 hour nurse triage line that may be free of charge.

Divorced/Separated Parents and Custodial Arrangements:

My 1st Clinic does not mediate disputes regarding financial responsibility for child's medical expenses between divorced/separated parents. By signing as guarantor, you agree to be financially responsible for your child's care, regardless of any existing custody or divorce agreements. We will provide receipts for paid medical bills upon request.

Billing Inquiries: Questions about a bill should be directed to our billing department at (866) 371-6118.

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.

In order to make sure that we can collect your portion of the bill once your insurance company processes the claim, My 1st Clinic has the ability to securely store a credit card on file (CCOF). Your card will only be charged the outstanding amount that your insurance company determines to be ‘patient responsibility’, as spelled out in your Explanation Of Benefits (EOB).

Once your insurance company processes the claim, an Explanation of Benefits (EOB) will be issued and a billing statement will be sent to the parent/guarantor. Any outstanding balance will be automatically charged to the credit card on file at the 1st of the following month. Once your card is charged, a receipt will be sent to you by email.

Please call our billing department at (866) 371-6118 with any questions regarding your EOB or bill prior to the end of the month. Payment can be made through your patient portal, by phone or online prior to the credit card on file being charged.

Your credit card on file may be used to pay your copayment or deductible at the time of your visit. This card will also be charged for missed appointments.

If you feel that an error was made with any charge to your card, please contact our billing department. This agreement does not restrict your right to appeal any charge made to your credit card.