PSYCHIATRY FEE SCHEDULE & GOOD FAITH ESTIMATE

Dr. Emily Wood, MD, PhD

Medical License A144603

Effective Date: June 1, 2026

I. Practice and Billing Model

All providers are out-of-network. You are responsible for the full cost of services at the time of care. If your plan includes out-of-network benefits (most PPOs do), you may be eligible for partial reimbursement — but this is not guaranteed and is determined solely by your insurer. Prescriptions and labs are typically covered separately by insurance.

Upon request, we will provide a superbill you can submit to your insurer. Note that doing so may prompt your insurer to request your medical records; we will not release records without your written authorization.

Contact your insurer before your first visit to understand your out-of-network benefits and deductibles. See the Shared Practice Policies & Patient Information document for full details.

II. Fee Schedule

Current Procedural Terminology (CPT) codes are used by insurance companies to determine reimbursement rate.

Psychiatric Diagnostic Evaluation with Med Management Includes complete medical and psychiatric history (including developmental, family, social histories), mental status examination, physical exam as needed, ordering of diagnostic and monitoring labs, establishment of an initial diagnosis, recommendations for treatment, initiation of medication management as indicated.

• Adults only — in person, 75 min: $1,050 (CPT 90792)
• All ages — in person 45 min + virtual 45 min: $1,250 (CPT 90792 & 99214)

Medication Management Includes discussion of potential risks, benefits, and side effects of medications, monitoring of medication effects and side effects, optimizing medication regimen, and ordering/reviewing laboratory tests.

• Virtual or in person, 22 min: $350 (CPT 99214)

Comprehensive Medication & Treatment Management Medication management as above with additional insight-oriented, problem-solving-focused therapy. ~45 min face-to-face time with Dr. Wood.

• Virtual or in person, 45 min: $550 (CPT 99214 + 90833)

Other and Administrative Time Time outside of scheduled appointments for phone or email consultations with patient/parent or other treatment team members, crisis assessment and management, insurance or prescription issues (outside of basic prior authorizations or pharmacy requests), writing letters, filling out forms, etc. For issues related to the recent appointment, the first 5-minute increment is not charged.

• Virtual or telephone, 15 min: $250 (CPT 99213)
• Interdisciplinary Team Conference, 30 min: $200 (CPT 99367)
• Administrative, per 5 min: $50 (CPT 99080 — most insurances do not reimburse)

Psychiatry Consultation Discussion of how psychiatric services (pharmacological, neuromodulatory, psychotherapeutic) may affect a person's treatment and prognosis. No prescriptions or documentation provided.

• Virtual or in person, 45 min: $500 (not reimbursable by insurance)

Psychiatry Expert Consultation Including forensic assessments, legal document review, preparation of significant documentation, appearances in court, depositions, and scheduled time addressing legal matters. Travel time is charged at a different rate.

• Virtual or in person, per hour: $800 (not reimbursable by insurance)

III. Frequency and Duration of Appointments

Frequency of appointments is determined by level of stability, frequency/level of care of other treatment modalities, and the medications being prescribed. More frequent appointments are warranted when:

• The patient's medications are currently being changed/titrated, especially during the first several months of treatment or following significant events
• A prescribed medication warrants increased monitoring of high-risk side effects (e.g., Clozapine, benzodiazepines)
• The patient is experiencing changes in life circumstances that may impact their mental health
• Other medical issues have arisen for the patient
• Unforeseen circumstances

To prescribe ongoing medications, Dr. Wood requires that all patients are seen at least every 3 months.

Dr. Wood may determine the appropriate medication management appointment (45 or 22 min) based on a patient's situation and needs. Factors include but are not limited to clinical complexity, level of care, time since last appointment, and child/adolescent vs. adult status (youth appointments may require separate interviews of both patient and guardians). Medication management appointments are for established patients who have completed a psychiatric diagnostic evaluation with Dr. Wood.

Written notice and an updated fee schedule will be provided before any increase takes effect.

IV. Deposit Policy

For initial intakes or assessments, a deposit equal to 50% of the appointment fee is required at the time of booking. This deposit is applied toward your appointment fee. If you cancel or reschedule with 48 or more hours' notice, your deposit will be refunded in full. If you cancel with less than 48 hours' notice or do not show, the deposit is forfeited.

V. Good Faith Estimate

Notice to patients: Under the No Surprises Act (42 U.S.C. §300gg-111 et seq.), you have the right to receive a Good Faith Estimate of expected charges before you receive services. This estimate is provided so you can make informed decisions about your care. It is not a contract and does not obligate you to receive the services listed.

Provider information:

• Provider name: Emily Wood, MD, PhD
• California Medical License: A144603
• Individual NPI: 1992114383
• Tax ID: 42-2206817
• Practice address: 11845 W Olympic Blvd, Suite 1250W, Los Angeles, CA 90064

Initiating Treatment

The Psychiatric Diagnostic Evaluation is billed separately from ongoing care and is not included in the annual scenario estimates below.

• Adults — Psychiatric Diagnostic Evaluation (75 min): $1,050
• Children & Adolescents — Psychiatric Diagnostic Evaluation (90 min): $1,250

Anticipated Annual Cost — Ongoing Care

Your annual costs depend on your clinical complexity and visit frequency. The estimates below reflect realistic ranges based on common treatment patterns. They do not include the initial intake appointment.

Scenario A — Active Treatment (medications being initiated or changed)

• Comprehensive Med Management (CPT 99214 + 90833) — 1–2 per year: $550–$1,100
• Brief Med Management (CPT 99214) — 5–10 per year: $1,750–$3,500
• Administrative/other time (CPT 99080/99367) — 0–120 min: $0–$1,200
• Estimated annual total: $2,300–$5,800

Scenario B — Stable Patient (treatment plan and medications are stable)

• Comprehensive Med Management (CPT 99214 + 90833) — 0–1 per year: $0–$550
• Brief Med Management (CPT 99214) — 4–6 per year: $1,400–$2,100
• Administrative/other time (CPT 99080//99367) — 0–60 min: $0–$600
• Estimated annual total: $1,400–$3,250

These scenarios are provided as illustrations. Dr. Wood will discuss which scenario most closely reflects your anticipated course of treatment.

Important Disclosures

• This Good Faith Estimate is based on information available at the time it was prepared. Your actual costs may be higher or lower depending on clinical need, visit frequency, and other factors.
• Services not listed in this estimate will be billed separately. You will be informed in advance if additional services are anticipated.
• This estimate is not a contract. You are not obligated to receive any service listed here.
• This estimate does not include services provided by other clinicians at this practice. Separate estimates are available from each treating provider.
• Late cancellation and no-show fees are not included in this estimate and are not reimbursable by insurance.

Your Right to Dispute

If the billed charges are $400 or more above this estimate, you have the right to initiate a Patient-Provider Dispute Resolution Process through the U.S. Department of Health and Human Services (HHS). This won't affect your care. Visit www.cms.gov/nosurprises or call 1-800-985-3059 for more information. You must initiate a dispute within 120 days of receiving your bill. There is no fee to use the dispute resolution process. This Good Faith Estimate is not a waiver of your right to dispute charges.

VI. Annual Review

This document must be reviewed and re-signed annually, as required by federal law. An updated estimate reflecting any fee changes will be provided at that time.

VII. Acknowledgment

By signing below, I acknowledge that:

• I have received and reviewed this Psychiatry Fee Schedule & Good Faith Estimate.
• I understand that this is an estimate of expected charges and not a guarantee of final cost.
• I understand my right to dispute charges that exceed this estimate by $400 or more.

Patient (or Legal Guardian if patient is a minor)

Signature: ___________________________________________

Date: ___________________________________________

Printed Name: ___________________________________________

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