Review & sign your consent forms

This notice describes how your health information may be used.

1. Uses. Treatment, payment, healthcare operations.
2. Disclosures. As required by law, public health, safety, and legal processes.
3. Rights. Access, amend, restrict, and request confidential communications.
4. Security. Reasonable safeguards are used.
5. Breach. You will be notified if required.
6. Business associates. Vendors may access data under contract.
7. State law. Stricter state privacy laws apply where applicable.
8. Complaints. You may file complaints without retaliation.
9. Acknowledgment. You acknowledge receipt.

By accepting electronically, you consent to treatment.

1. Services. May include psychiatric evaluation, medication management, and telehealth services.
2. Independent providers. Providers are independent contractors responsible for clinical care. SameDayPsych does not control clinical judgment.
3. Platform role. SameDayPsych provides administrative and technology services.
4. Risks. Treatment involves uncertainty and potential side effects.
5. No guarantee. Outcomes and prescriptions are not guaranteed.
6. Patient responsibilities. You must provide accurate information and follow treatment plans.
7. Emergencies. Not an emergency service. Call 911 if needed.
8. Confidentiality. Subject to legal exceptions.
9. Termination. Services may be discontinued where appropriate.
10. State licensure. Services depend on your physical location. Providers must be authorized in your state.
11. Location requirement. You must provide accurate real-time location.
12. Availability. Services not guaranteed in all states.
13. Complaints. Clinical concerns may be directed to providers.
14. Acknowledgment. You consent to treatment.

By accepting, you consent to telehealth.

1. Nature. Services provided via electronic communication.
2. Risks. Technical issues, privacy risks, and limitations.
3. Location. You must provide your physical location each visit.
4. Licensure. Providers must be authorized in your location.
5. Termination. Visits may end if compliance cannot be met.
6. Prescribing. Subject to federal and state law; not guaranteed.
7. Emergencies. Not for emergency care.
8. State law. Telehealth governed by your location\'s laws.
9. Acknowledgment. You consent to telehealth.

This Financial Policy & Billing Agreement governs all services through Geaux Health LLC, DBA SameDayPsych.

By clicking "I agree," creating an account, scheduling, or receiving services, you (Patient/Responsible Party/Guarantor) agree to be legally bound. This constitutes your electronic signature.

1. Guaranty of payment. You agree to be personally and fully responsible for all charges, regardless of insurance.
2. Agreement to pay. You agree to pay all charges not prohibited by law including deductibles, copays, coinsurance, denied claims, non-covered services, and out-of-network charges.
3. Insurance disclaimer. Insurance verification is not a guarantee of payment. You remain responsible for all balances.
4. Assignment of benefits. You assign all insurance benefits to SameDayPsych and/or its providers. Payments received by you must be forwarded.
5. Payment authorization. You authorize SameDayPsych to charge your payment method for all balances, including partial and recurring charges and retries.
6. Out-of-network services. You may be responsible for full charges except where prohibited by law.
7. Good faith estimate. Available where required. Estimates are not guarantees.
8. Missed appointments. Late cancellations and no-shows may be charged and are not billable to insurance.
9. Account default. Balances may become immediately due upon default.
10. Collections. SameDayPsych may pursue collections, including agencies, legal action, and recovery of costs.
11. Credit reporting. SameDayPsych will not report medical debt where prohibited by law.
12. Interest and fees. May apply as permitted by law.
13. Disputes. Billing disputes must be submitted within 30 days.
14. Suspension. Non-emergency services may be suspended for nonpayment.
15. Communications. You consent to billing communications via phone, email, text, or portal.
16. State-specific compliance. If your state law differs, it controls.

17. Limitation. SameDayPsych will not collect amounts or use methods prohibited by law.
18. Governing law. California law governs except where federal or other state law applies.
19. Agreement. You acknowledge and accept full financial responsibility.

By accepting, you make the following Assignment of Benefits and authorizations to Geaux Health LLC dba SameDayPsych (“Provider”) for any and all psychiatric, behavioral health, and related services rendered by Provider, its employees, contractors, or affiliates.

1. Assignment of Benefits. I irrevocably assign to Geaux Health LLC dba SameDayPsych all medical, mental health, behavioral health, and other insurance benefits, reimbursements, and rights to payment otherwise payable to me by any private insurance plan, health maintenance organization (HMO), preferred provider organization (PPO), exclusive provider organization (EPO), point-of-service (POS) plan, high-deductible health plan, ERISA plan, Medicare, Medicare Advantage, Medicaid, Tricare, Veterans Affairs, workers’ compensation, motor vehicle insurance, third-party liability carrier, or any other payor (collectively, “Insurer”), for any services rendered to me by Provider. I authorize and direct each Insurer to issue all benefit payments directly to Provider at Provider’s remit-to address. This assignment applies to current and future claims, all dates of service, and survives termination of this Agreement except as expressly limited by Section 11.
2. Authorization to Release Medical Information. I authorize Provider, and any of Provider’s clearinghouses, billing agents, electronic health record vendors, business associates, attorneys, and consultants, to release to my Insurer(s), and to receive from my Insurer(s), any and all medical, behavioral health, treatment, mental health, substance use, billing, financial, demographic, eligibility, and identifying information necessary for the purposes of: (a) determining eligibility, coverage, or benefits; (b) preparing, submitting, and adjudicating claims; (c) responding to denials, prepayment reviews, retrospective audits, post-payment reviews, recoupments, or appeals; (d) coordinating benefits with other payors; (e) responding to subpoenas, audits, or investigations relating to claims; and (f) any other lawful purpose related to securing payment for services. This authorization is HIPAA-compliant under 45 C.F.R. § 164.508 and complies with 42 C.F.R. Part 2 to the extent applicable.
3. Authorization to File and Pursue Claims. I authorize Provider to file claims with my Insurer(s) on my behalf, including initial submissions, corrected claims, resubmissions, reconsiderations, first-level and second-level appeals, external reviews, independent medical reviews, and any state or federal grievance processes. I authorize Provider to act as my authorized representative for claim purposes under any applicable plan documents, ERISA § 503, the No Surprises Act, state insurance codes, and any other governing law, and to execute any forms required to perfect this representation.
4. Out-of-Network Status — Disclosure and Acknowledgment. I expressly acknowledge that Provider is an OUT-OF-NETWORK (OON) provider with respect to most or all Insurers. I understand that: (a) the amount my Insurer pays may be substantially less than Provider’s billed charges; (b) my Insurer may apply an OON deductible, OON coinsurance percentage, separate OON out-of-pocket maximum, or balance-billing limitations; (c) Provider’s billed charges are based on Provider’s usual and customary fee schedule and are not bound by any Insurer’s allowed amount, fee schedule, or repricing; and (d) I remain financially responsible for any difference between Provider’s billed charges and the amount paid by my Insurer, except where prohibited by federal law (including the No Surprises Act) or controlling state law.
5. Patient Financial Responsibility. I am personally and financially responsible for: (a) any deductible amount; (b) any coinsurance or copayment; (c) any portion of charges denied, downcoded, or determined non-covered by my Insurer for any reason (including medical necessity denials, exclusions, frequency limits, prior authorization denials, claim filing errors after good-faith attempts, or coverage termination); (d) any balance not paid by my Insurer for any other reason; and (e) any services I receive that are not submitted to insurance at my election or Provider’s reasonable judgment. I authorize Provider to charge any payment method I have placed on file (including credit, debit, HSA, or FSA cards) for any patient-responsibility balance, after reasonable notice consistent with Provider’s Financial Policy.
6. No Surprises Act — Balance Billing Disclosure (Federal Notice). When you get emergency care or get treated by an out-of-network provider at an in-network hospital or ambulatory surgical center, you are protected from surprise billing or balance billing. The federal No Surprises Act protects you from balance billing in those settings. For non-emergency, scheduled OON services from Provider, the No Surprises Act’s balance-billing protections generally do not apply once you have given valid written consent (where consent is permitted) or where the service is not within a federally protected setting. By signing below, I acknowledge that I have received this notice and understand my rights under the No Surprises Act. I understand I may visit www.cms.gov/nosurprises for more information, or call 1-800-985-3059 with questions or to file a complaint.
7. Coordination of Benefits. I authorize Provider to: (a) coordinate benefits between any primary, secondary, and tertiary Insurers; (b) submit claims in the order required by each Insurer’s coordination-of-benefits rules; (c) recoup any overpayment from a primary Insurer when a secondary Insurer is later identified; and (d) treat any payment received from a non-primary Insurer in error as held in trust for, and forwarded to, the proper Insurer.
8. Forwarding of Misdirected Payments. If, despite this Assignment, an Insurer issues a benefit payment directly to me for services rendered by Provider, I shall hold such payment in trust for Provider and forward the full amount to Provider, by check or electronic transfer, within fourteen (14) calendar days of receipt. I authorize Provider to charge any payment method on file for the amount of any such misdirected payment that I have not forwarded within thirty (30) days of receipt.
9. Lien on Insurance Benefits and Recoveries. To the maximum extent permitted by applicable law, I grant Provider a contractual and equitable lien on, and a first-priority security interest in, any and all insurance benefits, settlement proceeds, third-party liability recoveries, motor-vehicle insurance proceeds, workers’-compensation awards, and other recoveries payable to me arising out of any incident, illness, or injury for which Provider rendered services. I authorize my Insurer, attorney, employer, and any third-party administrator or carrier to recognize this lien and to honor it before disbursing funds to me.
10. Limited Power of Attorney for Claim Purposes. I appoint Provider as my limited attorney-in-fact for the limited purposes of: (a) endorsing checks and electronic payments issued in my name by an Insurer for services rendered by Provider; (b) signing claim forms, appeals, authorized-representative designations, ERISA § 503 representative forms, assignment confirmation forms, and HIPAA authorizations as required to obtain payment; and (c) communicating with Insurers regarding any of the foregoing. This power of attorney is durable, is coupled with an interest, and survives until revoked in writing pursuant to Section 11.
11. Term and Revocation. This Assignment of Benefits and the authorizations herein remain in effect until I revoke them in a signed, written notice delivered to Provider at billing@samedaypsych.com or by mail to Provider’s remit-to address. Revocation is prospective only; it does not affect any claim, appeal, payment, or action already submitted, pending, or completed in reliance on this Assignment, and does not extinguish the lien granted in Section 9 with respect to services already rendered.
12. Subrogation, Negotiation, and Settlement. I authorize Provider to: (a) negotiate with my Insurer regarding the amount of any allowed amount, repricing, downcoding, denial, recoupment, or audit; (b) settle, compromise, or accept reduced payment in Provider’s sole discretion; and (c) pursue or release subrogation claims and recovery from third parties on services Provider has rendered to me, in each case without further consent or notification.
13. Scope of HIPAA Authorization. The medical-information release in Section 2 is limited to the purposes described therein. I understand: (a) my information may be subject to redisclosure by the recipient and may no longer be protected by HIPAA; (b) I may revoke this authorization in writing at any time, except to the extent Provider has already taken action in reliance; (c) treatment, payment, enrollment, or eligibility for benefits may not be conditioned on this authorization, except as permitted under 45 C.F.R. § 164.508(b)(4); and (d) this authorization expires three (3) years from the date of signature unless revoked sooner.
14. Electronic Signature. I agree that my typed name, IP address, browser identifier, and timestamp captured at signing constitute a valid electronic signature with the same force and effect as a handwritten signature under the Electronic Signatures in Global and National Commerce Act (E-SIGN, 15 U.S.C. § 7001 et seq.) and the Uniform Electronic Transactions Act (UETA), and may be used as evidence of my agreement in any administrative, claim, or legal proceeding.
15. Governing Law; Severability; Conflicts. This Assignment is governed by the laws of the State of California, without regard to conflict-of-laws principles, except where federal law (including ERISA, HIPAA, the No Surprises Act, or applicable Medicare/Medicaid provisions) or the law of another state in which I receive services preempts. If any provision of this Assignment is found unenforceable, the remaining provisions remain in full force and effect, and the unenforceable provision shall be reformed to the minimum extent necessary to make it enforceable.
16. State-Specific Provisions. Where the law of the state in which I reside or in which I received services provides greater protections, narrower assignments, or specific notice requirements (including but not limited to assignment-restriction laws, anti-balance-billing statutes, and patient bill-of-rights statutes), those provisions shall control over conflicting provisions of this Assignment to the minimum extent required.
17. Acknowledgment. I acknowledge that I have read this Assignment of Benefits and Authorization to Release Medical Information in its entirety, that I have had the opportunity to ask questions, that I am at least eighteen (18) years of age (or signing as the legally authorized representative of a patient), and that I sign of my own free will. A scanned, photocopied, or electronic copy of my signature shall have the same legal effect as the original.

By accepting, you agree to private pay terms.

1. Private pay status. Applies when insurance is not used or not applicable.
2. Agreement to pay. You agree to pay disclosed rates.
3. No insurance billing. Claims may not be submitted unless stated.
4. Superbills. May be provided; reimbursement not guaranteed.
5. Good faith estimate. Available where required.
6. Estimates. Not guarantees.
7. Payment authorization. Card on file may be charged.
8. Missed appointments. Fees apply.
9. Non-covered services. You are responsible.
10. No guarantees. No guarantee of prescriptions or outcomes.
11. Collections. Unpaid balances may be collected as permitted by law.

12. State law. Applicable law controls.
13. Agreement. You accept responsibility for payment.