PATIENT SERVICE AGREEMENT AND CONSENT 

Millie Medical Group, P.C. is honored to provide you with personalized support and care. Please read and sign the following agreement (“Agreement”), which lists services provided and the policies and procedures regarding scheduling, payment methods, confidentiality and compliance, and consent to email, text, and application messaging. 

This Agreement governs the services provided by Millie Medical Group, P.C. and any affiliate or contracted medical care providers (“Provider”). Millie, Inc. (“Millie”) provides management and administrative services to the Provider. (Collectively, Provider and Millie are referred to in this document as “us,” “we,” and “our.”)

1. Services

1. You agree to receive medical and/or mental health services, including related care management, medication management, and wellness services (the “Services”). You understand the risks, benefits, and alternatives of receiving these Services and have had the opportunity to ask questions. You may withdraw your consent to receive services by no longer seeking Services from Provider. 
2. Services may be provided via telehealth, which involves the use of synchronous (at the same time) and asynchronous (at different times) audio, video, or other electronic communications to interact with you, consult with your health care provider, and/or review your medical or mental health information for the purpose of diagnosis, therapy, follow-up, and/or education. During your telehealth consultation with Provider, details of your medical history and personal health information may be discussed with other health professionals through the use of interactive video, audio, and telecommunications technology. The benefits of telehealth include having access to medical specialists and additional medical information and education without having to travel outside of your local health care community. A potential risk of telehealth is that because of your specific medical needs, or due to technical problems, a face-to-face consultation still may be necessary after the telehealth appointment. Additionally, in rare circumstances, security protocols could fail, causing a breach of patient privacy. The alternative to telehealth consultation is a face-to-face visit with a physician or other healthcare provider.
3. You may ask your Provider any questions you may have regarding Telehealth Services, and you understand that you can refuse or discontinue Telehealth Services and are not prevented from receiving in-person health care during a specified course of health care and treatment after agreeing to receive services via telehealth. You agree not to share your appointment link with anyone unauthorized to attend your appointment.
4. Any licensed provider providing Telehealth Services is also required by California law to provide you with their license or registration number and the type of license or registration each time before they begin Telehealth Services. Your Provider will provide you with a notice explaining that they are licensed/registered and regulated by the California Board of Registered Nursing and the Medical Board of California, and their license/registration can be checked and complaints against the licensee/registrant can be made through the Board's website or by contacting the Board. By signing below, you agree that you have read the California notice to consumers regarding provider licensure.

Telehealth Services should not be used for a medical emergency; in a medical emergency or mental health emergency, or if you are feeling suicidal or that you cannot keep yourself or others safe, you should dial 911, call or chat with the 988 Suicide & Crisis Lifeline, and/or go to your local hospital’s Emergency Room.

2. Scheduling Services. All Services can be scheduled by visiting millieclinic.com. 

3. Cancellation Policy.  You understand that your appointment, whether virtual or in person, must be canceled at least twenty-four (24) hours in advance or you will be responsible for full payment for the missed visit, unless your insurance prohibits us from billing you for missed visits.

4. Payment Methods. You understand and agree that payment for services may be required to be made prior to or at the time of service, except for the portion of the payment that may be covered by your insurance plan. Provider accepts payment in the form of credit or debit card; if you do not have a credit or debit card, please contact us. If we accept your insurance and you will be using insurance to cover some or all of the cost of your appointment, you should contact your Provider ahead of your appointment to ensure that your insurance is accepted. You should be prepared to pay any co-payments at the time of the appointment. You further understand and accept your financial responsibility for any portion of the bill not covered by your health insurer or health plan. If Provider is out-of-network for your insurance, you will be responsible for submitting the claim to your insurer for reimbursement. 

If you dispute any charges, you must notify us in writing within sixty (60) days after you are charged. We may, in our sole discretion, offer credits on a case-by-case basis, such as, for example, in the event of an error in the amount you were charged.

For informational purposes only, a link to the federal Centers for Medicare and Medicaid Services (CMS) Open Payments web page is provided here. The federal Physician Payments Sunshine Act requires that detailed information about payment and other payments of value worth over ten dollars ($10) from manufacturers of drugs, medical devices, and biologics to physicians and teaching hospitals be made available to the public.

5. Credit Card. ‍During the booking process, you may be asked to provide a credit card or other payment method (“Payment Method”) to confirm and hold your appointment. By providing a Payment Method, you acknowledge that the Payment Method is collected solely for the purpose of confirming your appointment and is not charged for clinical services and that we do not store your credit card information on our systems. Credit card information provided during the booking process is transmitted through our third-party scheduling platform to confirm your booking. You understand and acknowledge our cancellation policy set forth in Section 3 above, including that failure to cancel at least twenty-four (24) hours in advance may result in financial responsibility for the missed visit.

Billing for clinical services is separate from the booking process and may be handled by a third party to whom we have assigned billing and collection rights.

6. Good Faith Estimate. Patients who don’t have certain types of health insurance coverage, or who choose not to use their insurance coverage (including uninsured and self-pay patients), have the right to receive a Good Faith Estimate (“GFE”) of expected charges before services are provided. If you would like a GFE or cost estimate for your upcoming services, please contact Millie at support@millieclinic.com or (510) 495-0310. Millie will obtain the GFE for you or direct the appropriate billing entity or Provider to provide it.

7. Confidentiality and Compliance. Provider will take appropriate precautions to keep your health information confidential and to not disclose it without your consent. You are also protected under the provisions of the federal Health Insurance Portability and Accountability Act (“HIPAA”) and any other applicable federal and state laws related to protection of patient information. You have received a copy of our Notice of Privacy Practices (“NPP”), of which the most up-to-date version is posted on our website.

8. Mental Health Services Disclaimer. Mental health services may involve discussing sensitive aspects of your life in person or via telehealth; you may experience uncomfortable feelings like sadness, guilt, anger, frustration, loneliness, or helplessness. If at any point you experience significant increased distress or have thoughts of harming yourself or others, you agree to notify your mental health provider so that an appropriate level of support can be provided. Your mental health provider may utilize a set of psychological symptom questionnaires in order to assist with determining a diagnosis and track your progress in counseling, and may discuss the nature of these assessments and your results when applicable.

9. Notice to Clients. The Board of Behavioral Sciences receives and responds to complaints regarding services provided within the scope of practice of (marriage and family therapists, licensed educational psychologists, clinical social workers, or professional clinical counselors).  You may contact the board online at www.bbs.ca.gov, or by calling (916) 574-7830. 

Consent to E-mail, Text, and Application Messaging. When you provide us with your e-mail and/or phone number or communicate with us electronically via e-mail, phone call, text message, or messages via the Millie Websites, you consent to receive communications from Millie and its agents and affiliates electronically through any phone number(s) or e-mail addresses you provide. You verify that any contact information provided to us, including, but not limited to, your name, mailing address, email address, your residential and/or business telephone number(s), and/or your mobile telephone number(s), is true and accurate. You further verify that you are the current subscriber or owner of any telephone number(s) that you provide. If we discover that any information provided in connection with your registration is false or inaccurate, we may suspend or terminate your account at any time. You agree to promptly notify us if you change your contact information by updating this information in your account settings.

You verify that any contact information provided to us, including, but not limited to, your name, mailing address, email address, your residential and/or business telephone number(s), and/or your mobile telephone number(s), is true and accurate. You further verify that you are the current subscriber or owner of any telephone number(s) that you provide. If we discover that any information provided in connection with your account is false or inaccurate, we may suspend or terminate your account at any time. You agree to promptly notify us if you change your contact information by updating this information in your account settings.

You acknowledge that telephone calls to or from us may be monitored and recorded, and you agree to such monitoring and recording.

By voluntarily providing your telephone number, you expressly agree to receive calls and text messages (e.g., SMS, MMS, over-the-top (OTT) messages, or successor protocols or technologies) from or on behalf of us, including via autodialer, artificial voice and/or prerecorded message. These calls and texts may include informational or transactional communications (e.g., regarding your account, transactions, our services and offerings, billing and amounts owed, and your relationship with us) and/or marketing communications.

You acknowledge that automated calls and/or text messages may be made to your telephone number even if registered on any state or federal Do Not Call list. You agree to receive automated and/or marketing calls and text messages from us, even if you cancel your account or terminate your relationship with us, except if you opt out (see below).

Message frequency varies. Standard text messaging and data rates may apply through your service provider. You represent and warrant that you are authorized to incur such charges and acknowledge that we are not responsible for such charges.

You understand that you do not have to agree to receive automated marketing calls/texts as a condition of purchasing any goods or services.

For help, text HELP in response to any text message from us or contact Customer Service at (510) 495-0310.

Your consent to receive automated and/or telemarketing calls and text messages and your consent to Electronic Messages is completely voluntary. You may opt out at any time by replying STOP to any text message we send you, by emailing your request and phone number to privacy@millieclinic.com, or by calling (510) 495-0310. You may also opt out through your account or by following the unsubscribe instructions in any electronic communication you receive from us. You acknowledge and agree to accept a final text message confirming your opt-out.

Your withdrawal of consent will be effective within a reasonable time after we receive your withdrawal notice described above. Your withdrawal of consent will not affect the legal validity or enforceability of the Terms provided to and accepted by you. Even if you opt out of Electronic Messages, we may need to continue to send you certain communications electronically regarding the Services. You will not be able to opt out of those communications.

If you withdraw your consent to receive communications electronically, certain Services or functionalities may become unavailable to you, or may prevent you from using the Services entirely.

Please allow up to ten (10) business days to process any opt-out request. Please note that if you opt out of automated calls and/or text messages, we reserve the right to make non-automated calls to you.

It is possible that third parties may have your contact information and you may continue to receive communications from these third parties despite an opt-out request to us. We are not responsible for unwanted contact from third parties. Please contact third parties directly to inform them of your communication preferences.

We will make reasonable efforts to ensure that Electronic Messages are secure, private, and meet your communication preferences; however, we cannot guarantee that information shared via electronic means is 100% secure given the risks inherent in electronic communication.

You must notify us immediately of any breach of security or unauthorized use of your device(s) that may impact the e-mail address(es) and/or phone number(s) provided to us. Although we will not be liable for losses caused by any unauthorized use of your device(s), you may be liable for our losses due to such unauthorized use.

In consideration of the services provided by Millie, you release Millie, and any affiliates or agents acting on its behalf, from any and all claims, demands, causes of action, lawsuits, injuries, damages, losses, liabilities, or other harms resulting from or relating to phone calls, text messages, emails or other electronic messages, including without limitation any claims based on any asserted violations of the law (including without limitation the Telephone Consumer Protection Act (TCPA), the Truth in Caller ID Act, the CAN-SPAM Act, the Fair Debt Collection Practices Act, the Fair Credit Reporting Act, the Health Insurance Portability and Accountability Act, federal or state wiretapping statutes, any similar state and local acts or statutes, and any federal or state tort or consumer protection laws).

You further agree to indemnify, defend, and hold harmless us against any claims, demands, causes of action, lawsuits, injuries, damages, losses, liabilities, costs and expenses (including reasonable attorneys’ fees) or other harms relating to any asserted violations of law brought by third parties, including under the TCPA or any state law equivalent statutes or regulations, arising from your voluntary provision of a telephone number that is not owned by you and/or your failure to notify us of any changes in your contact information, including telephone number.

We shall have the exclusive right to choose counsel, at your expense, to defend any such claims.

Your obligations under this Section will survive termination of this Agreement.

10. Updates/Revisions.  We may update this Agreement upon thirty (30) days’ notice to you.  Notice will be provided via e-mail.‍

11. Disclaimers.  TO THE MAXIMUM EXTENT NOT PROHIBITED BY LAW, EXCEPT IN CASE OF NEGLIGENCE OR WILLFUL MISCONDUCT, MILLIE AND ITS AFFILIATES, PROVIDERS, EMPLOYEES, OFFICERS, DIRECTORS OR AGENTS WILL NOT BE RESPONSIBLE FOR ANY LOSS OR DAMAGE, INCLUDING PERSONAL INJURY OR DEATH, RESULTING FROM ANYONE'S USE OF OR INABILITY TO USE THE MEDICAL SERVICES.

The Services are intended for use only within the United States and its territories. Millie makes no representation that the Services are appropriate, or are available for use outside the U.S. Those who choose to access and use our Services from outside the U.S. do so on their own initiative, at their own risk, and are responsible for compliance with applicable laws.

12. Limitation of Liability. TO THE MAXIMUM EXTENT NOT PROHIBITED BY LAW, IN NO EVENT WILL MILLIE AND ITS AFFILIATES, PROVIDERS, EMPLOYEES, OFFICERS, DIRECTORS OR AGENTS BE LIABLE FOR ANY CONSEQUENTIAL, EXEMPLARY, INCIDENTAL, SPECIAL OR PUNITIVE DAMAGES, INCLUDING WITHOUT LIMITATION THOSE RELATING TO LOST PROFITS OR THE COST OF SUBSTITUTE PRODUCTS OR SERVICES ARISING OUT OF OR IN CONNECTION WITH THE SERVICES OR FROM THE USE OF OR INABILITY TO USE THE SERVICES, WHETHER BASED ON CONTRACT, WARRANTY, PRODUCT LIABILITY, TORT OR OTHER LEGAL THEORY AND EVEN IF WE HAVE BEEN INFORMED OF THE POSSIBILITY OF SUCH DAMAGES. SOME JURISDICTIONS DO NOT ALLOW THE EXCLUSION OR LIMITATION OF LIABILITY FOR CONSEQUENTIAL OR INCIDENTAL DAMAGES, SO THE ABOVE EXCLUSION MAY NOT APPLY TO YOU.

This Agreement was last modified on June 23, 2026.