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Our Policies

For your convenience, we’ve gathered all our key policies and resources. Kindly read the full details below.

👉 Office Policy

1. Please use respectful behavior:

Our policy is to treat everyone who enters/calls our office with kindness and respect. We understand that sometimes situations occur that are stressful and upsetting. However, we have a zero-tolerance policy for parents/guardians/patients who use curse words, threatening, and/or vulgar language with our staff. If this occurs, your family will be dismissed from our practice.

2. Appointment wait times:

We strive to minimize any wait time; however, emergencies do occur and will take priority over a scheduled visit. We appreciate your understanding.

3. Sick Visit During Well Visit:

A "Well Visit" or "Well Check" does not require a co-payment under the Patient Protection and Affordable Care Act. For your convenience, your physician or provider may discuss or treat your child for a medical condition during your child's well visit. This saves you from having to make several trips to our office. As a result, a co-payment or deductible may be required by your insurance company if discussions beyond your child's preventative care occur.

4. Prescription refills:

Please allow up to 2 business days for routine refills. Some refills may take longer depending on pharmacy stock/availability and/or need for prior authorization. Please remember that refills can only be given to patients who have been seen within the last 3 months.

5. Clean office:

No food or drinks are allowed in the waiting room or the exam rooms. Please watch your children! Any damages or vandalism will result in an invoice for damages or dismissal from the practice.

👉 Appointment Policy

We schedule appointments in such a way that your child can be properly checked-in, examined, and treated in a timely manner. Although this cannot always be done, we strive to accomplish this and have several policies in place to accommodate your family’s needs:

1. Appointment Confirmations:

As a courtesy, we will remind you of your upcoming appointments via phone/text message. If you do not confirm your appointment in at least one manner within 24 hours of your appointment, we will assume you are out of the country or unavailable and will automatically cancel your appointment. A “No show” fee of $40 may be added to your account. This fee must be paid before a new appointment is scheduled. 3 missed/no-shows will result in dismissal from the practice.

2. Late arrivals:

If you are over 20 minutes late for your appointment, we will do our best to accommodate. However, on certain days it may be necessary to reschedule your appointment.

3. Sibling Add Ons:

If you arrive with your child for a visit and request to add on a sibling, we count that as a walk-in. If the schedule does not allow appropriate time to properly care for your child, we will ask that you schedule the sibling later that day. All we ask is for a phone call ahead of time to let us know.

4. Walk-Ins:

We do not accept walk-ins. If a parent walks-in for a non-emergency visit, we will do our best to accommodate you and your child, however, you may be asked to return when there is availability. This allows our providers to spend the appropriate amount of time with you and your child.

👉 Financial Policy

We must emphasize that as pediatric providers, our relationship is with you, not your insurance company. While the filling of insurance claims is a courtesy that we extend to our patients, all charges are strictly your responsibility.

1. Insurance benefits / Coverage and Network:

It is the parent/guardian’s responsibility to understand which benefits are covered or not covered by their insurance program. The parent/guardian is fully responsible for all fees denied as non-covered services, as well as any deductibles, coinsurance, copayments, or other patient responsibilities, including charges incurred when services are out of network. It is also the patient’s responsibility to know their doctor’s network status, and we encourage checking with your insurance to avoid unnecessary charges. If we do not participate in your insurance plan, payment in full is expected at the time of the visit; however, we can provide an invoice that may be submitted to your insurance for possible reimbursement.

2. PCP designation

If you have an HMO insurance product, you are required to elect a Primary Care Provider (PCP). It is your responsibility to elect a provider with Fairway Children’s Medical Group prior to attending any visits to our office.

3. Self-pay:

Self-pay patients are expected to pay for services in FULL at the time of the visit. You must acknowledge that you have no insurance at the time of service.

4. Patient balances:

Billing statements are issued once we receive the Explanation of Benefits (EOB) from your insurance provider. Payment is due within 30 business days of the statement date. Any outstanding balance must be paid in full prior to scheduling or attending future appointments. Accounts with unpaid balances exceeding 90 days may be referred to an outside collection agency, and continued care with our practice may be discontinued.

5. Newborns:

Newborns are typically covered under their mother’s insurance plan for the first 30 days. You must enroll your baby for ongoing care. Any claims denied by the insurance company will be the responsibility of the parents / guardian.

6. Copays:

We are required by our insurance contracts to collect all co-payments at the time of service. The parent/guardian who brings the child at time of service will be responsible for the copay. A $10 service fee will be charged in addition to your co-payment if the co-payment is not paid by the end of that business day.

7. Medi-Cal:

If your child has Medi-Cal and is also covered under a private health insurance, we are required by law to file claims with the private insurance policy first. Medi-Cal plans are always considered as secondary insurance. If Medi-Cal is not informed that your child also has private insurance, they have the right to retract payment from previously paid claims. If this occurs, then the entire balance will be the responsibility of the parent/guardian on file.

8. No show fee:

We understand that unexpected situations may arise, so the fee for the first missed appointment (no-show) will be waived. A $40 fee may be charged for each additional missed appointment. Three or more no-shows may result in additional fees and possible dismissal from the practice.

9. Well Check plus sick visit:

A “Well Visit” or “Well Check” does not require a co-payment under the Patient Protection and Affordable Care Act. However, for your convenience, your physician or provider may discuss or treat additional medical concerns during your child’s visit to avoid the need for multiple appointments. If care is provided beyond preventive services, your insurance company may require a co-payment or deductible. This may include management of pre-existing or chronic conditions (such as constipation, ADHD, anxiety, depression, asthma, eczema, or allergies) or evaluation and treatment of new or acute concerns (such as fever, ear pain, sore throat, abdominal pain, cough, rashes requiring further work-up, wart removal, joint pain, or behavioral concerns). For questions about your specific coverage, benefits, or co-payments, please contact your insurance company directly, as coverage varies by plan, and our practice cannot determine individual insurance benefits.

👉 Credit Card on File Policy

Fairway Children’s Medical Group (FCMG) requires that a valid Credit Card be kept on file.

The policy is designed to:

 Help avoid all billing related fees.

 Streamline the billing process in our oƯice and eliminate the expenses related to handling overdue

accounts.

 Focus our time and energy on your children and their medical care.

The card information is stored electronically in an encrypted form and cannot be viewed by our office staff. Your signature will authorize the card to be used only when your balance becomes past due.

How the policy works:

1. At the time of your registration or check-in, you will be asked for your credit card information to be

electronically stored in encrypted form in our system. Only the last four digits are visible to our staff.

2. We will bill your insurance carrier as a courtesy for all charges related to the visit.

3. When we receive an explanation of benefits (EOB) from your insurance, we will send you a statement if

needed. If we have not received payment within 30 business days, we will charge the credit card on file

for the balance due (on the statement)

4. If we attempt to use your card and it is declined or has expired, we will send you a new statement with a

note attached asking for current credit card information.

👉 Divorce Policy

Unless court documents state otherwise, our office will presume that parents share joint custody of their children and have equal rights to access medical records and make decisions about their care.

We understand that family changes like separation or divorce can be challenging. While we empathize, we focus solely on your child's medical needs. To best advocate for your child, we will remain impartial and not engage in parental disputes. Parents must communicate directly with each other regarding their child's care. Our office will not discuss legal issues or mediate disputes.

Our office follows all legal orders but requires official documentation to ensure compliance. Custody arrangements must be established through the courts or the Department of Children and Families.

COMMUNICATION:

We are not responsible for sharing visit information with each parent separately, and we will not contact the non-attending parent after visits. Either parent can access visit details with a signed medical release form. Appointment reminders will be sent to the primary phone number on file; this automated process cannot be customized by appointment or withheld at a parent's request.

APPOINTMENTS WITH PARENTS:

We accommodate appointment requests from either parent concerned about their child's health. However, appointments will not be scheduled solely for one parent to document their perspective. If this occurs, we reserve the right to deny future requests.

BILLING:

Our contract with your insurance provider requires that copays be collected at the time of service. Payment is expected from the attending parent, and a receipt can be provided. Accounts with unpaid copays will incur a late fee.

AUTHORIZED ADULTS:

Either parent may authorize a non-parent, such as a stepparent, grandparent, or partner, to accompany their child to an appointment. Without legal documentation stating otherwise, we cannot restrict an authorized adult from attending. The parents are responsible for coordinating who is authorized to accompany the child.

DISPUTES:

Our providers and staff will not mediate or participate in disputes between parents. If disagreements interfere with care or disrupt our office, we reserve the right to discharge your family from our practice.

We encourage parents to prioritize their child's well-being. These situations are difficult, but cooperation is essential to support your child's health and emotional needs. Our shared priority is ensuring your child receives the care they deserve.

👉 Notice of Privacy Practices

Your Information. Your Rights. Our Responsibilities.

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

Effective Date: January 1, 2026

Questions? Contact our Privacy Officer: Jackyln Chan, MD • 909-594-3382 • [email protected]

Offices:

West Covina — 2707 E Valley Blvd, Ste 215, West Covina, CA 91792

Diamond Bar — 888 S Brea Canyon Rd, Ste 330, Diamond Bar, CA 91789

Chino — 5385 Walnut Ave, Ste 6, Chino, CA 91710

Your Rights

You have the right to:

• Get a copy of your paper or electronic medical record

• Correct your paper or electronic medical record

• Request confidential communication

• Ask us to limit the information we share

• Get a list of those with whom we’ve shared your information

• Get a copy of this privacy notice

• Choose someone to act for you

• File a complaint if you believe your privacy rights have been violated

Your Choices

You have some choices in the way that we use and share information as we:

• Tell family and friends about your condition

• Provide disaster relief

• Provide mental health care

• Market our services and sell your information

• Raise funds

Our Uses and Disclosures

We may use and share your information as we:

• Treat you

• Run our organization

• Bill for your services

• Help with public health and safety issues

• Do research

• Comply with the law

• Respond to organ and tissue donation requests

• Work with a medical examiner or funeral director

• Address workers’ compensation, law enforcement, and other government requests

• Respond to lawsuits and legal actions

To the extent that we have your substance use disorder patient records, subject to 42 CFR part 2, we will not share that information for investigations or legal proceedings against you without (1) your written consent or (2) a court order and a subpoena.

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. Ask us how to do this.

• We will provide a copy or a summary of your health information, usually within 15 days of your request as required by California law. 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. Ask us how to do this.

• We may say “no” to your request, but we’ll tell you why in writing within 60 days.

Request confidential communications

• You can ask us to contact you in a specific way (for example, home, office, or cell phone) or to send mail to a different address.

• We will say “yes” to all reasonable requests.

Ask us to limit what we use or 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 could affect your care. If we agree to your request, we may still share this information in the event that you need emergency treatment.

• 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’ve 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 privacy 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 someone has authority to act as your personal representative — such as a parent or guardian of a

minor patient, a person with your medical power of attorney, or 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 any action.

File a complaint if you feel your rights are violated

• You can complain if you feel we have violated your rights by contacting our Privacy Officer 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/hipaa/filing-a-complaint/index.html.

• 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 or payment for your care

• Share information in a disaster relief situation

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 or safety.

In these cases we never share your information unless you give us written permission:

• Marketing purposes

• Sale 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

How do we typically use or share your health information?

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.

Example: 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 your care, and contact you when necessary.

Example: 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.

Example: 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 or required 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.

In all cases, including those listed below, if we have substance use disorder patient records about you, subject to 42 CFR part 2, we cannot use or share information in those records in civil, criminal, administrative, or legislative investigations or proceedings against you without (1) your consent or (2) a court order and a subpoena.

Help with public health and safety issues

We can share health information about you for certain situations such as:

• Preventing disease

• Helping with product recalls

• Reporting adverse reactions to medications

• Reporting suspected abuse, neglect, or domestic violence

• 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

• 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 in this notice unless you tell us we can in writing. If you tell us we can, you may change your mind at any time. Let us know in writing if you change your mind.

For more information see: www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/noticepp.html.

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 web site.

Additional Notices That Apply to This Practice

California law

California’s Confidentiality of Medical Information Act (CMIA) gives your medical information additional protection beyond federal law. In general, anyone in California who receives your medical information may not share it further except as the law specifically requires or permits.

Minor patients and sensitive services

Certain health information of minor patients — including records related to mental health, substance use, sexual or reproductive health, and other services a minor may lawfully consent to under California law — receives special confidentiality protection. We will not disclose that information without the consent of the person who controls it under the law, except as the law requires or permits.

Proof of immunization

With your agreement on behalf of yourself or your child, we will disclose proof of immunization to a school that is required by law to have such information before admitting a student.

Substance use disorder (Part 2) records

If we ever receive or maintain substance use disorder treatment records that are protected under federal law (42 CFR part 2), we apply the additional protections that law requires. As noted above, we will not use or share those records in legal proceedings against you without your written consent or a court order

accompanied by a subpoena.

Patient portal

You may access certain health information through our patient portal at https://fcmgca.pcc.com/portal/session/new.

Complaints

Complaints about this notice or about how this practice handles your health information should be directed to our Privacy Officer listed on page 1. You may also file a complaint with the U.S. Department of Health & Human Services Office for Civil Rights:

Region IX, Office for Civil Rights

U.S. Department of Health & Human Services

90 7th Street, Suite 4-100, San Francisco, CA 94103

(800) 368-1019 • (800) 537-7697 (TDD)

[email protected]

We will not retaliate against you for filing a complaint.

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