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, etc) 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 your 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 this 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.

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 of 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.
• Out-of-pocket payments: 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 an 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 disclosures except for those about treatment, payment, and health care operations, and certain other disclosures.
• 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 it electronically. We will provide it 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.
• File a complaint if you feel your rights are violated: You can complain by contacting us using the information above. You can also file a complaint with the U.S. Department of Health and Human Services Office for Civil Rights. 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. Tell us what you want us to do, and we will follow your instructions to:

• Share information with your family, close friends, or others involved in your care.
• Share information in a disaster relief situation.
• We never share your information for marketing purposes, the sale of your information, or psychotherapy notes unless you give us written permission.
• Reproductive Health Care: We are prohibited from using or disclosing your health information to identify, investigate, prosecute, or determine the liability of any person for the act of seeking, obtaining, providing, or assisting in lawful reproductive health care.
• Attestations: For certain requests for reproductive health information—such as those for health oversight, judicial proceedings, or law enforcement—we must obtain a signed attestation from the requester confirming the request is not for a prohibited purpose.

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

• Treat you: We use and share health information with other professionals who are treating you.
• Run our organization: We use and share your information to run our practice, improve your care, and contact you when necessary.
• Bill for your services: We use and share your information to bill and get payment from health plans or other entities.
• Comply with the law: We will share information if state or federal laws require it, including for public health and safety issues, research, or in response to a lawsuit or subpoena, except where restricted by federal law regarding reproductive health care privacy.
• Substance Use Disorder Records: For health information protected by federal substance use disorder laws, we will obtain your written consent for most disclosures. Once consent is given, we may share this information for treatment, payment, or clinic operations as permitted by law.

Participation in Health Information Exchanges (HIE):
My 1st Clinic participates in the Los Angeles Network for Enhanced Services (LANES) and the California Health and Human Services (CalHHS) data exchange framework.

• This state-wide system facilitates the secure sharing of your health information among healthcare providers, insurers, and other authorized entities to improve the coordination and quality of your care.
• Through this network, we may share medical history, treatment information, and test results for treatment, payment, or health care operations. This allows for better-coordinated care and quicker access to information in emergencies.
• Opting-Out: You may opt out of your information being accessible through the HIE. To do so, please request an HIE Opt-Out Form from our front desk . Note that even if you opt out, certain information relating to public health reporting and controlled dangerous substances will still be available to providers as permitted by law.

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.

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.

Notice to Patient/Parent/Guardian: We are required to provide you with a copy of our Notice of Privacy Practices, which states how we may use and/or disclose your health information. In addition to this copy, you may request a physical copy or access this notice on our website: www.my1stclinic.com .

By signing below, I acknowledge that I have received and reviewed My 1st Clinic's Notice of Privacy Practices: