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Acknowledgement of Receipt of Notice of Privacy Practices

To Our Patients:

In accordance with Federal Law on the Patient Privacy, please read the following:

This statement is to advise you that our office has a Privacy Policy (complete policy in waiting room) in place to protect your medical information. In brief, our policy states that our office will keep your
medical record information confidential and will use it only for treatment, payment and healthcare operations. The office may release information to other doctors during emergencies, or cases of
neglect and abuse. Our policy identifies your rights to access your records, request restrictions on who can see and be informed of your medical information. In short, to keep your communications
with this office confidential.

Our Privacy Policy can be reviewed in its entirety, or you may request a copy.

DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.

You have my permission to release my medical information to the following: (please check and list name and phone number)

Patient Information

I hereby authorize my insurance benefits to be paid directly to the physician and I understand that I am financially responsible for all non-covered charges. Payment is due and payable at the time services are rendered. I understand that my credit card is on file and that any remaining balance I owe may be charged to my credit card. I also authorize my physician to release any information to my insurance company for the processing of my insurance claims. HMO patients who do not have prior authorization to see Dr. Onuma or Dr. Lee will be financially responsible for any charges incurred.

DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.

Appointment Cancellation Policy:

We appreciate your understanding and cooperation in ensuring we can provide timely and highest quality care to our patients. We kindly ask that you provide us with at least 48 hours notice if you need to cancel or reschedule your appointment. This allows us to offer the appointment slot to another patient who may need medical care.

Cancellation Fees: If you cancel your appointment with less than 48 hours notice, or if you fail to show up for your appointment without notifying us, a fee of $50 for office visit, and $100 for scheduled procedures will be applied.

How to Cancel or Reschedule: To cancel or reschedule your appointment, please call our office during business hours at 650-342-7432 (M-F, 9:00am-5:00pm). You may also leave a voicemail if you are calling after hours. Please do not cancel appointments via email, as we may not receive the notice in time.

Exceptions: We understand that emergencies and unforeseen circumstances arise. If you have a genuine emergency or illness that prevents you from attending your scheduled appointment, please contact us as soon as possible so that we can waive any applicable cancellation fees. Please note, we consider exceptions on a case-by-case basis.

Late Arrivals: If you arrive late for your appointment, we will do our best to accommodate you, but please be aware that your appointment may need to be rescheduled to the end of the day in order to ensure that our other patients are not inconvenienced. We appreciate your cooperation with our cancellation policy. By adhering to these guidelines, you help us provide better service to you and all our patients.

Artificial intelligence (AI) Technology Consent:

AI technology, such as ambient listening transcription, is increasingly being utilized in the healthcare field for patient communications, telehealth visits, transcription, and more. To ensure the confidentiality and security of your protected health information, these third party applications are required to adhere to all applicable regulations including HIPAA. AI and similar technologies are integral to enhance and assist with your healthcare.

Patient Acknowledgement

By signing below, you acknowledge and consent to the appointment cancellation policy and use of AI technologies. Any applicable fees are not billable to insurance and are the sole responsibility of the patient.