Policies & Notices
Documents & Notices
1. Shared Practice Policies & Patient Information
Key points:
Payment is due at time of service; a credit card on file is required. All providers are out-of-network — you pay in full and may seek reimbursement from your insurer using a superbill we provide.
Confidentiality is protected, with limited legal exceptions (imminent danger to self or others, child/elder abuse reporting, court orders).
Emergencies: Do not contact your provider. Call 911, text/call 988, or the LA County Help Line at (800) 854-7771.
Cancellations require 48 hours' notice for intakes, 24 hours for all other appointments. First no-show is free; subsequent ones are charged in full. Intakes require a 50% deposit at booking.
Communication via Spruce Health or Jane App during business hours only — not for emergencies, not via social media.
You have the right to access your records, seek a second opinion, refuse treatment, and end the treatment relationship at any time.
2. Notice of Privacy Practices
Key points:
What's protected: Anything that identifies you and relates to your health, treatment, or billing — records, notes, and personal identifiers like your name and address.
Routine uses without your consent: Treatment, billing, and basic practice operations. We may also contact you for appointment reminders.
Uses that never require your consent: Mandatory reporting (child/elder abuse), court orders, public health and law enforcement purposes, and certain government functions.
Uses that always require your written consent: Psychotherapy notes, marketing, and sale of your information. (We do not market or sell your PHI.)
Your rights: You can request restrictions on how your information is used, access or correct your records, request confidential communications, get a list of disclosures, and be notified of any breach.
Complaints: If you believe your privacy rights have been violated, you may file a complaint with this practice or with the HHS Office for Civil Rights — without fear of retaliation.
3. Telehealth Informed Consent
Key points:
How it works: Sessions are conducted via HIPAA-compliant video platform (Zoom). The same privacy protections that apply to in-person care apply to telehealth.
Benefits: Greater access and convenience, including the ability to see a specialist remotely.
Risks: Technical failures, poor video quality, or security breaches could affect the quality or privacy of your care. Telehealth has limitations compared to in-person visits.
Your location matters: Your provider is licensed in California only. If you join from another state, they may not be able to prescribe medication or assist in an emergency. Always inform your provider of your location at the start of each session.
Your responsibilities: Join from a private, quiet location; never attend while driving; don't record sessions without written consent; notify your provider if anyone else can see or hear the session.
You can withdraw consent at any time — this will not affect your future care unless in-person services are not logistically available, in which case referrals will be provided.
Emergencies: Call 911 or go to the nearest ER. For mental health crisis, call or text 988.
4. Email/Text/Portal Communication Consent
Key points:
Three communication channels are available: the secure client portal (Jane), email, and text/SMS. The portal is the most secure and strongly recommended for anything involving health information.
Email and text are not fully secure. By consenting to these channels, you acknowledge and accept the associated privacy risks.
All communications — regardless of channel — become part of your official medical record.
You choose your preferences by signing this form. You may update your communication preferences at any time in writing.
These channels are not for emergencies. For urgent needs, call 911, text/call 988, or contact your provider through the portal during business hours.
5. Financial Responsibility & Credit Card Authorization
Key points:
You are financially responsible for all services rendered, regardless of whose card is on file. Signing this form is personal, sole financial accountability.
A valid credit card is required on file at all times. No exceptions.
Charges are processed automatically — at time of service for sessions; on the date of the missed appointment for late cancellations and no-shows. No individual notification is given before standard charges.
Declined or disputed charges must be resolved within 3 business days. Unresolved balances may result in services being placed on hold or referred to collections.
Co-parent and co-guardian arrangements are entirely outside this practice. The person who signs is solely responsible; we do not mediate billing between parties.
6. AI-Assisted Documentation Consent
Key points:
This practice uses AI tools to support clinical documentation across psychiatry, psychology, and occupational therapy.
In psychiatry, an ambient AI listens during sessions and generates a text transcript. Audio is not stored and cannot be played back — only the text transcript is retained.
All AI platforms are HIPAA-compliant and have signed Business Associate Agreements. Your data is not used for commercial purposes or to train AI models.
Your clinician reviews and approves all AI-generated documentation before it is finalized.
Consent is voluntary. You may decline or withdraw at any time without affecting your care.
7. EW Informed Consent for Psychiatric Treatment
Key points:
This form governs your care with Dr. Emily Wood, MD, PhD and should be read alongside the Shared Practice Policies document.
Psychiatric evaluation and treatment may include medication, psychotherapy, and coordination with other providers. Treatment goals and options will be discussed with you at the outset.
Medication risks and alternatives will be reviewed before any prescription is initiated. You have the right to ask questions and refuse any recommended treatment.
Minors: Parents or legal guardians must provide written consent. Dr. Wood will also seek the minor's assent as a meaningful part of the clinical relationship.
Legal proceedings: Dr. Wood serves as your treating clinician only — not as an independent evaluator. Any involvement in legal matters outside standard appointments is billed at the expert consultation rate.
8. EW Fees & Good Faith Estimate
Key points:
This document discloses the fees for psychiatric services with Dr. Emily Wood and satisfies the No Surprises Act Good Faith Estimate requirement.
You have the right to receive this estimate in writing before your first appointment, request an updated estimate at any time, and dispute a final bill that exceeds this estimate by $400 or more.
This is an estimate only — actual costs may vary based on your treatment needs and the services you receive.
Dispute rights: visit www.cms.gov/nosurprises or call 1-800-985-3059.
9. Medical Board Acknowledgment
Key points:
Medical doctors are licensed and regulated by the Medical Board of California.
To verify a license or file a complaint: www.mbc.ca.gov | licensecheck@mbc.ca.gov | (800) 633-2322.
Your signature confirms you have received and understood this notice.
In a Mental Health Crisis?
If you or someone you know is in immediate danger, do not use this portal or contact your provider. These channels are not monitored continuously and cannot guarantee a timely response.
Call 911 for life-threatening emergencies. Call or text 988 — Suicide and Crisis Lifeline, available 24/7. LA County Help Line: (800) 854-7771 — available 24/7 at dmh.lacounty.gov