FINANCIAL RESPONSIBILITY & CREDIT CARD AUTHORIZATION

Effective Date: June 1, 2026

I. This Form

This form establishes the financial terms and conditions of care at Emily Wood, MD, PhD. Please take the time to read it carefully before signing. Your signature confirms your understanding of and agreement to all policies outlined below.

II. Financial Responsibility

All patients and/or their designated responsible parties are expected to take full ownership of the costs associated with their care at Emily Wood, MD, PhD. Services covered under this agreement span the full scope of what this practice offers, including occupational therapy, psychiatry, clinical psychology, and any other professional services delivered by clinicians within Emily Wood, MD, PhD.

If the card held on file is registered under a different name than the responsible party, this does not diminish or transfer financial accountability. The individual signing this form remains personally and solely responsible for ensuring that all charges are paid in full and on time, by whatever means necessary.

Should any charge be declined, contested, or reversed, the responsible party agrees to address the outstanding balance through an alternative payment method without delay. Accounts that remain unresolved following reasonable notice may be referred to an outside collections agency, and continued access to services may be suspended or discontinued as a result.

Emily Wood, MD, PhD plays no role in mediating or enforcing financial arrangements between separated parents, co-guardians, or any other parties. The person who signs this form bears sole financial responsibility for all services rendered, and any private agreements regarding cost-sharing or reimbursement between parties must be managed independently and outside of Emily Wood, MD, PhD entirely.

A current and valid credit card in the responsible party's name is required to be kept on file throughout the duration of care at Emily Wood, MD, PhD.

III. Credit Card Authorization

Your signature on this form constitutes explicit authorization for Emily Wood, MD, PhD and its treating clinicians to process charges to the card on file for any of the following:

• Psychiatry Services
• Clinical psychology Services
• Assessment Services
• Occupational therapy sessions
• Initial occupational therapy evaluation
• Late cancellations and no-shows: charged at the full session rate
• Additional professional services prorated at the standard hourly rate, which may include:
  • Clinical report writing and treatment summaries
  • Preparation of disability or other professional documentation
  • Phone or email correspondence exceeding 10 minutes in duration
  • Professional consultation with other providers (with your prior consent)

All charges are processed automatically — at the time of service for scheduled appointments, and on the date of the missed or cancelled appointment for late cancellations and no-shows. Your agreement to these terms at the point of signing removes the need for individual notification prior to each transaction for standard charges as described above.

IV. Card On File

Requests to update or remove a card on file must be submitted in writing. A replacement card must be provided at the same time, as an active card on file is a condition of ongoing care at Emily Wood, MD, PhD. Failure to maintain valid payment information may result in services being placed on hold or discontinued.

V. Cancellation & No-Show Policy

All scheduled appointments across every service offered at Emily Wood, MD, PhD are subject to the following policy:

A minimum of 24 hours notice is required to cancel or reschedule any appointment. The full session fee will be applied to:

• Any cancellation made with less than 24 hours notice
• Any appointment for which no notice was received

Where both the clinician and the responsible party are in agreement that a missed appointment was the result of circumstances entirely beyond the patient's control, an exception may be considered at the clinician's discretion. It should be noted that fees incurred through late cancellations or missed appointments fall outside the scope of insurance reimbursement and are not eligible for submission via superbill.

VI. Declined Payments

If a payment is unsuccessful for any reason, the responsible party will be contacted and is expected to provide valid alternative payment information within 3 business days. Balances left unresolved beyond this window may result in a hold on services or referral to a third-party collections agency.

VII. Changes to this Notice

We reserve the right to revise or change provisions on this Notice. We will implement the new Notice provisions effective for all services provided and confidential information we maintain. The most current version of this notice will be available on our website at https://www.emilywoodmdphd.com/policies. The Notice will contain the effective date on the top of the first page.

VIII. Acknowledgment and Agreement

By signing below, I confirm the following:

• I have read and understood every section of this form and agree to all terms outlined herein
• I accept full financial responsibility for all services provided to the patient named above by any clinician at Emily Wood, MD, PhD
• I authorize Emily Wood, MD, PhD and its clinicians to automatically process charges to the card on file for sessions, late cancellations, no-shows, and any additional professional services as described above
• I understand that charges for standard services will be processed without individual prior notification, as agreed upon at the time of signing
• I commit to maintaining a valid card on file for the full duration of care at Emily Wood, MD, PhD
• I understand that any financial arrangements between co-parents, guardians, or other parties are entirely outside the scope of Emily Wood, MD, PhD and will not be mediated or enforced here
• I accept responsibility for resolving any declined, disputed, or reversed charges promptly and in full

Patient (or Legal Guardian if patient is a minor)

Signature: ___________________________________________

Date: ___________________________________________

Printed Name: ___________________________________________

Relationship (if signing on patient's behalf): ___________________________________________