1 · Out-of-Pocket Practice

The practice of Gordon Wong MD, MPH ("the Practice") is an out-of-pocket, fee-for-service psychiatric practice. The Practice does not contract with commercial insurance, Medicare, Medi-Cal, or any preferred-provider panel, and does not submit claims on behalf of patients. I am financially responsible for the full fee for every service rendered, regardless of any insurance coverage I may have.

2 · Fee Schedule and Superbills

The Practice's current fee schedule has been provided to me separately. I understand that fees may be revised from time to time. On request, the Practice will provide an itemized superbill containing the diagnosis and procedure codes I would need to submit my own claim to an out-of-network insurer; filing and pursuing such claims is solely my responsibility.

3 · What I Authorize the Practice to Charge

I authorize the Practice to charge the credit or debit card I provide ("Card on File") for:

• Initial-consultation and follow-up session fees at the Practice's then-current rates;
• Late-cancellation and no-show fees as described in Section 4;
• Charges for substantive telephone, email, or coordination-of-care work performed outside of session, billed at the Practice's hourly rate;
• Any other charge I expressly authorize at the time of service.

4 · Cancellation Policy

There is no charge for any appointment cancelled with at least 48 hours' notice. Appointments cancelled with less than 48 hours' notice, and no-shows, will be charged at the full session rate.

The Practice will not charge for unavoidable absences (illness, emergency, and similar circumstances) at the Practice's discretion. The Practice reserves the right to apply this exception more strictly for patients for whom cancellations have become a recurring problem.

5 · Timing of Payment

Payment is due at the time of each session. To allow this policy to be honored without delay, I agree to upload my current billing information through the Practice's secure portal at gordonwongmd.com at least 48 hours before my first appointment, and to keep that information current thereafter. Cancellation and no-show fees may be charged immediately.

6 · How My Card Information Is Stored

I understand that the Practice does not store my full card number on its own systems. Card information is transmitted through a HIPAA-compliant connection directly to the Practice's PCI-DSS-compliant payment processor (Elavon Converge), which returns a tokenized reference. The Practice retains only the last four digits, the expiration month/year, and the token used to process future charges. I agree not to send my full card number by ordinary email.

7 · Receipts

I understand that an itemized receipt for each charge is available on request from the Practice.

8 · Right to Revoke

I may revoke this authorization at any time by written notice to the Practice. Revocation takes effect after any session already rendered, and any other balance owed to date, has been paid in full. The Practice may decline to schedule further appointments if a current authorization is not on file.

9 · Updating My Card

I will promptly notify the Practice if my card is lost, replaced, expires, or is otherwise no longer valid. An invalid card does not relieve me of my financial obligations; any balance will become directly payable by check, cash, or another card.

10 · Disputes

If I believe a charge is incorrect, I agree to contact the Practice in writing within 30 days of the charge so the matter may be resolved directly before initiating a chargeback through my card issuer.

11 · Electronic Signature

By typing my full legal name and clicking "Submit Authorization," I am providing my electronic signature with the same legal force and effect as a handwritten signature, in accordance with the federal E-SIGN Act (15 U.S.C. §7001 et seq.) and the California Uniform Electronic Transactions Act (Cal. Civ. Code §1633.1 et seq.).