Forms & Documents

Financial Policy

Thank you for choosing Paula S. Gordy LISW, LLC for your mental health care. We are committed to providing you with the best possible services. The following is a statement of our financial policies. Please read it carefully and indicate your understanding and agreement by signing below.

Payment at Time of Service

All copayments, coinsurance, deductibles, and self-pay fees are due at the time of service. Payment is expected at each session unless other arrangements have been made in advance with our office.

Accepted Payment Methods

We accept the following forms of payment: cash, personal check, and credit or debit card (Visa, MasterCard, Discover).

Insurance Billing

As a courtesy, we will submit claims to your insurance company on your behalf. We will make reasonable efforts to verify your benefits prior to your first appointment. However, verification of benefits is not a guarantee of payment. You are ultimately responsible for understanding your insurance coverage and for any balance not covered by your insurance plan.

Client Responsibility

You are responsible for any charges not paid by your insurance, including but not limited to copays, coinsurance amounts, deductibles, and services determined to be non-covered or out-of-network by your plan. If your insurance denies a claim for any reason, you will be responsible for the full amount of the charges.

Cancellation and No-Show Policy

We require at least 24 hours advance notice if you need to cancel or reschedule an appointment. Appointments canceled with less than 24 hours notice, or missed without notice (no-show), may be subject to a missed appointment fee. Insurance does not cover missed appointment fees. Repeated missed appointments may result in discharge from services.

Returned Check Fee

A fee will be assessed for any check returned by the bank for insufficient funds. This fee is in addition to the original amount owed.

Past Due Balances and Collections

Balances that remain unpaid for more than 90 days may be referred to a collections agency. If an account is sent to collections, you will be responsible for any additional fees incurred during the collections process. We will make every effort to work with you on a payment arrangement before taking this step.

Self-Pay Rates

Self-pay rates are available upon request. Please contact our office for current session fees. We strive to make our services accessible and are happy to discuss payment options with you.

Sliding Scale

A sliding scale fee may be available based on demonstrated financial need. Eligibility is determined on a case-by-case basis. Please speak with our office if you would like to inquire about this option.

Good Faith Estimate — No Surprises Act

Under the No Surprises Act (effective January 1, 2022), you have the right to receive a Good Faith Estimate of the expected charges for services. This estimate is provided in advance of your scheduled services and is not a contract or guarantee of final charges. If you receive a bill that is at least $400 more than your Good Faith Estimate, you can dispute the bill. For questions or more information about your right to a Good Faith Estimate, visit cms.gov/nosurprises or call 1-800-985-3059.

Telehealth Services Overview

Telehealth involves the delivery of mental health services using interactive audio and video technology, allowing you and your therapist to communicate in real time from different locations. Telehealth is used as an alternative to in-person visits when appropriate and when both the client and therapist agree it is suitable for the client's needs.

Benefits of Telehealth

Telehealth can provide greater convenience and flexibility, especially for clients who live in rural areas, have transportation difficulties, have mobility limitations, or have scheduling constraints. Telehealth allows continuity of care during situations that may prevent in-person visits, such as inclement weather or illness.

Risks and Limitations

While telehealth is an effective method of delivering mental health services, there are some risks and limitations to be aware of:

• Technology may fail or become disrupted during a session due to internet connectivity, software issues, or hardware problems.
• Despite best efforts to ensure privacy and security, there is always some risk that electronic communication could be intercepted or accessed by unauthorized parties.
• Telehealth may not be appropriate for all clinical situations. Your therapist will discuss with you if in-person services are recommended.
• In the event of a clinical emergency, the limitations of telehealth may reduce the ability to provide immediate in-person intervention.

Technology Requirements

To participate in telehealth sessions, you will need a device (computer, tablet, or smartphone) with a working camera, microphone, and speakers, as well as a reliable internet connection. You are responsible for ensuring your device and internet connection are functional before your scheduled session.

Privacy and Security

Paula S. Gordy LISW, LLC uses a HIPAA-compliant telehealth platform to protect your privacy and the security of your health information. All video sessions are encrypted and meet federal standards for the protection of electronic health information. Your therapist will conduct sessions from a private location.

Client Responsibilities

To protect your own privacy during telehealth sessions, you agree to:

• Participate from a private, quiet location where you cannot be overheard by others.
• Ensure no unauthorized individuals are present in your room during the session.
• Not record any portion of the telehealth session without prior written consent.
• Inform your therapist of your physical location at the start of each session for safety purposes.
• Maintain a reliable internet connection and have your device charged or plugged in.

Right to Withdraw Consent

You have the right to withdraw your consent to telehealth services at any time. Withdrawing consent will not affect your right to receive in-person services. If you wish to discontinue telehealth, please notify your therapist.

Emergency Procedures

In the event of a mental health emergency during a telehealth session, your therapist will attempt to assist you remotely. However, if you are in immediate danger, your therapist may need to contact local emergency services (911) at your location. It is important that your therapist knows your physical location during each session so that emergency services can be dispatched if necessary. Please have the address of your current location available at the start of each session.

Recording Policy

Telehealth sessions are not recorded by the therapist or the practice. Neither party may record any portion of a telehealth session without the prior written consent of all participants.

Technical Difficulties

If the technology fails during a session and the connection cannot be re-established within a reasonable time, your therapist will attempt to contact you by phone to either continue the session by phone or to reschedule. If you experience technical difficulties before a session, please contact our office at (641) 856-2688.