Disclaimers
Lisa Abdilova Andresen, LCSW #104761
LTAA Licensed Clinical Social Worker, PC
DBA: Let’s Talk About Anything
2339 Third Street, Suite 50, SF, CA, 94107
NOTICE OF PRIVACY PRACTICES
A federal law, HIPAA (Health Insurance Portability and Accountability Act), was established to provide clients with certain rights and protections for your Protected Health Information (PHI). It is important for clients to know how health information can be disclosed, accessed, and used for the purpose of treatment, payment, and healthcare operations.
PHI USE AND DISCLOSURE
I have a legal duty to safeguard your PHI. With some exceptions, I can only release information about your treatment to others if you have signed a written authorization form that authorizes me to release that treatment information. Only with your consent, may I provide your PHI to a family member, friend, or other person that you indicate is involved in your care or the payment of your healthcare. You may revoke all such authorizations at any time, provided each revocation is in writing.
Certain limitations to confidentiality are outlined in the corresponding Informed Consent for Therapy. Your PHI may be used and disclosed by those who are involved in your care, such as a psychiatrist, primary care physician, or office staff member for the purpose of providing, coordinating, or managing your healthcare treatment and related services. The PHI accessed or disclosed would be no more than is necessary to accomplish the purpose for which the use or disclosure is made.
PROFESSIONAL RECORDS
Your clinical record can include information about 1) your reasons for seeking therapy services; 2) a description of how the challenges you are facing are impacting your life; 3) your concerns/symptoms and diagnosis; 4) the goals set for your treatment; 5) your progress towards those goals; 6) the past treatment records received from other providers; 7) your treatment history; 8) reports of any professional consultations; 9) your billing records; and 10) copies of any reports that have been sent to anyone.
HOW I PROTECT YOUR PRIVACY
I am committed to maintaining and protecting confidentiality of your personal and sensitive information. I have secure procedures for accessing, labeling, and storing your confidential information. Records are stored under lock and key or with electronic password protection and/or encryption.
Before I provide any information to an insurance company or other third party requesting it, I would discuss the request with you to be sure you wish me to honor it. Patient privacy with regard to your records is protected by law, although records can be subpoenaed by a court of law, and I could be required to provide the records or information in them.
CLIENT RIGHTS
You have rights with regard to your records. You can restrict what information from your record is disclosed to others and/or request to amend your record. You may also make a written request to see or have a copy of your record. Given the record’s professional clinical nature, it is recommended that clients requesting their records review them with a mental health clinician to provide you with the opportunity to clarify and ask questions.You also have the right to decline further treatment, change therapists, and request referrals. You have the right to raise, at any time, any question about my therapeutic approach and/or the progress of your treatment.
FOR MORE INFORMATION OR COMPLAINTS
If you want more information about your privacy rights, do not understand your privacy rights, disagree with a decision that I made about access to your confidential information, or believe your privacy rights have been violated and wish to file a complaint, you may contact the Board of Behavioral Sciences (916.574.7830). You may also file a written complaint with the Secretary of the US Department of Health and Human Services at 200 Independence Ave S.W, Washington DC, 20201. I will not take any retaliatory action against you if you file a complaint.
CONSENT FOR TELEHEALTH SERVICES
OVERVIEW
“Telehealth” includes the practice of healthcare delivery, diagnosis, consultation, treatment, transfer of medical data, and education using interactive audio, text-message, video, email, or data communication. Electronic systems used will incorporate network and software security protocols to protect the confidentiality of client identification and imaging data and will include measures to safeguard the data and to ensure its integrity against intentional or unintentional corruption.
TECHNOLOGY
The technology platforms utilized by my therapist and me may include, but not be limited to:
Google Services with HIPAA Business Associate Agreement (BAA), including Google Mail, Docs, Calendar, Sheets, Drive, and Voice
Spruce Health with HIPAA BAA for phone calls, voicemails, text messages
Zoom will be utilized for video therapy sessions. HIPAA Compliant security precautions will include encryption, multi-factor authentication, password-protection, and/or private virtual meeting rooms
Simple Practice with HIPAA Business Associate Agreement for PHI collection, assessment questionnaires, messaging, sharing documents, secure payments, and clinical documentation.
Signal Messenger for encrypted mobile text messaging for non-sensitive discussions (ie: logistics, scheduling, and billing) and resources
Amazon Blink for office video security and client arrival notification which is password protected with recordings deleted on a regular basis
COVID-19 EXCEPTIONS
In light of the COVID-19 pandemic, Lisa Andresen, LCSW will maintain compliance with the "U.S Department of Health and Human Services (HHS) Announcement of Enforcement Discretion for Telehealth Remote Communications", the "Statement on Telehealth in Pursuant to Executive Order N-43-20", and any applicable interstate telehealth laws and regulations throughout the public health emergency.
CLIENT RIGHTS
I understand that I have the following rights with respect to telehealth:
I have the right to withhold or withdraw my consent at any time without affecting my right to future care or treatment nor risking the loss or withdrawal of any treatment benefits to which I would otherwise be entitled.
The laws that protect the confidentiality of my medical information also apply to telehealth. As such, I understand that the information disclosed by me during the course of my therapy is generally confidential. However, there are both mandatory and permissive exceptions to confidentiality, including, but not limited to reporting child, elder, and dependent adult abuse; expressed threats of violence towards an ascertainable victim; and where I make my mental or emotional state an issue in a legal proceeding. I also understand that the dissemination of any personally identifiable images or information from the telehealth interaction to researchers or other entities shall not occur without my written consent.
LIMITATIONS
I understand that there are risks and consequences with telehealth, including, but not limited to the possibility, despite reasonable efforts on the part of my therapist that:
the transmission of my health information could be disrupted or distorted by technical failures;
the electronic transmission and/or storage of my health information could be interrupted by unauthorized persons.
In the case of any known breaches of confidentiality, Lisa Andresen, LCSW will follow HIPAA, HI-TEC, Security and Privacy Guidelines on appropriate disclosures and remedies.
In addition, I understand that telehealth based services and care may not be as complete as face to face services. I also understand that if my therapist believes I would be better served by face-to-face therapeutic services, arrangements will be made accordingly.
SAFETY
For safety and regulatory purposes, the address of my current location will be confirmed at the beginning of virtual sessions.
In the case of a mental health emergency, I understand I can do one or more of the following (without waiting for communication back from my therapist):
Call 9-1-1 or present to nearest police station
Visit closest emergency room
Call 2-1-1 for resource referrals, directions, contact information..
Call National Suicide Prevention Lifeline: 1-800-273-8255
Text HOME to 741741 for the Crisis Text Line
Call San Francisco Crisis Line: (415) 781-0500
Visit 24/7 Mental Health Dore Urgent Care: 52 Dore St, SF, CA, (415) 553-3100
Call the National Domestic Violence Hotline: 1-800-799-7233
SEARCH ENGINE & SOCIAL MEDIA POLICY
Lisa Andresen, LCSW utilizes separate professional social media accounts named "Let's Talk About Anything" to promote mental health advocacy, share resources, blog posts, and practice updates. Lisa Andresen, LCSW does not expect or request any current or former clients to follow these professional accounts unless they voluntarily choose to subscribe to updates. Due to the importance of minimizing dual relationships that could compromise our therapeutic relationship, please note Lisa Andresen, LCSW does not accept friend requests from current or former clients on personal social networking accounts.
In order to respect and protect your privacy and confidentiality, Lisa Andresen, LCSW will not follow or interact with your social media accounts or messages. Lisa Andresen, LCSW also will not conduct electronic searches about clients without your consent unless there is a clinical reason or emergency where information obtained electronically might protect you from harm and/or be necessary for treatment.
GOOD FAITH ESTIMATE
In accordance with Section 2799B-6 of the Public Health Service (“No Surprises”) Act, you’ll be provided a Good Faith Estimate with the range of costs of services that are reasonably expected to address your mental health care needs.
I expect that your treatment will require recurring individual therapy sessions with the option to continue treatment for at least the next 12 months if it is clinically indicated. This Good Faith Estimate is not a contract. It does not obligate you to accept the services listed. You also have the right to terminate services at any time.
Maximum possible charges per year will be calculated and shared prior to your first session.
Depending on the frequency of our sessions, our total number of sessions over the next year could range between 10 (monthly) to 25 (bi-weekly) to 50 (weekly) sessions (accounting for vacations, holidays, sick time, and emergencies). However, depending on how treatment progresses and/or potential other circumstances, we may have more or fewer sessions.
POSSIBLE SERVICE CODES:
The following is a detailed list of expected services for individual psychotherapy services.
*90834 - Psychotherapy, 38-52 min (most common)
90837 - Psychotherapy, 53-60 min
0591T - Health and Well-Being Coaching (Initial Session)
0592T - Personal Health Coaching
90791- Psychiatric Diagnostic Evaluation without medical services
Possible Location(s) Services Provided:
Office (11) - 2339 3rd St, Suite 50, SF, CA, 94107
Office (11) - 582 Market St, Ste 1401, SF, CA, 94104
Telehealth Provided in Client's Home (10)
Telehealth Provided Other than in Client's Home (02)
DISCLAIMER
This Good Faith Estimate shows the costs of services that are reasonably expected for your health care needs based on information known at the time the estimate was created.
The estimated range of costs are valid for 12 months from the date of the Good Faith Estimate, unless I send you an updated version. The Good Faith Estimate does not include any unknown or unexpected costs that may arise during treatment. You could be charged more if complications or special circumstances occur. The estimate doesn’t include any information about what your health plan may cover if you submit a claim for possible out-of-network insurance reimbursement. This means that your final cost of services may be different than this estimate.
Please also keep in mind our Informed Consent for Services Agreement, which notes that if you arrive more than 15 minutes after our session start time, no-show, or cancel our session less than 24 hours beforehand, you will be billed the full session rate as a late cancellation fee.
CLIENT RIGHTS TO DISPUTE RESOLUTION
In the unlikely case that you are charged more than this Good Faith Estimate, please let me know of any discrepancies as soon as possible, and we can problem solve accordingly.
If you are charged $400 or more than this Good Faith Estimate, you have the right to formally dispute the bill.
You may start a dispute resolution process with the U.S. Department of Health and Human Services (HHS). If you choose to use the dispute resolution process, you must start the dispute process within 120 calendar days (about 4 months) of the date on the original bill. There is a $25 fee to use the dispute process. If the agency reviewing your dispute agrees with you, you will have to pay the price on this Good Faith Estimate. If the agency disagrees with you and agrees with me as your health care provider, you will have to pay the higher amount.
To learn more and get a form to start the process, go to www.cms.gov/nosurprises or call HHS at (800) 368-1019.
For questions or more information about your right to a Good Faith Estimate or the dispute process, visit www.cms.gov/nosurprises or call (800) 368-1019.
You are also welcome to contact me with any questions at 415-890-3576 or lisa@letstalkaboutanything.com
FOUNDER COACHING
CONFIDENTIALITY
This coaching relationship, as well as all information (documented or verbal) that the Client shares with the Coach as part of this relationship, is bound by the principles of confidentiality. The Coach agrees not to disclose any information pertaining to the Client without the Client’s verbal or written consent. The Coach will not disclose the Client’s name to any third parties without the Client’s consent. Occasionally, Coach engages in consultation with other industry professionals. It is mutually understood that the purpose of such professional consultation is to benefit the Client. It is also mutually understood that no personally identifiable information would be provided in order to protect Client’s confidentiality.
However, please be aware that the Coach-Client relationship is not considered a legally confidential relationship (like the medical and legal professions) and thus communications are not subject to the protection of any legally recognized privilege.
Confidential Information does not include information that: (a) was in the Coach’s possession prior to its being furnished by the Client; (b) is generally known to the public or in the Client’s industry; (c) is obtained by the Coach from a third party, without breach of any obligation to the Client; (d) is independently developed by the Coach without use of or reference to the Client’s confidential information; or (e) the Coach is required by statute, lawfully issued subpoena, or by court order to disclose; (f) is disclosed to the Coach and as a result of such disclosure the Coach reasonably believes there to be an imminent or likely risk of danger or harm to the Client or others; and (g) involves illegal activity. The Client also acknowledges his or her continuing obligation to raise any confidentiality questions or concerns with the Coach in a timely manner.
When the coaching agreement involves 2 or more coaching clients, a no secrets policy will be maintained in order to maintain transparency and communication among the team. The Coach will encourage Clients to practice expressing needs and boundaries directly with team members, however please note that content shared with Coach individually may influence subsequent individual and team coaching sessions.
SCOPE OF PRACTICE DISCLOSURE
It is mutually understood that Lisa Andresen is a Licensed Clinical Social Worker #104761 in the state of California. It is also understood for the sake of a Founder Coaching engagement that she is not working in her professional capacity as a therapist and is therefore not subject to California or Federal regulatory laws managing the professional practice of mental health professionals. It has not been made explicit nor has it been implied that a Founder Coaching Client is a mental health patient under the professional care of Lisa Andresen. In the course of this engagement, should the need for mental health counseling arise, appropriate referrals can be made to licensed professionals for such a service.
Founder coaching does not involve the diagnosis or treatment of mental disorders and that coaching is not to be used as a substitute for mental health care, substance abuse treatment, or other professional advice by legal, medical or other qualified professionals and that it is the Client’s exclusive responsibility to seek such independent professional guidance as needed. If Client is currently under the care of a mental health professional, it is recommended that the Client promptly inform the mental health care provider of the nature and extent of the coaching relationship agreed upon by the Client and the Coach.
Last updated 3-24-24