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Terms and Policy

The privacy of your health information is important to me. I will maintain the privacy of your health information and I will not disclose your information to others unless you tell me to do so, or unless the law authorizes or requires me to do so.

A new federal law commonly known as HIPAA requires that I take additional steps to keep you informed about how I may use information that is gathered in order to provide health care services to you. As part of this process, I am required to provide you with the attached Notice of Privacy Practices and to request that you sign the attached written acknowledgement that you received a copy of the Notice. The Notice describes how I may use and disclose your protected health information to carry out treatment, payment or health care operations and for other purposes that are permitted or required by law. This Notice also describes your rights regarding health information I maintain about you and a brief description of how you may exercise these rights.

If you have any questions about this Notice please contact Liza Gellerstedt, LCSW at (678) 962-7288.


I am required by applicable federal and state law to maintain the privacy of your health information. I am also required to give you this Notice about my privacy practices, legal obligations, and your rights concerning your health information ("Protected Health Information" or "PHI"). I must follow the privacy practices that are described in this Notice (which may be amended from time to time).

For more information about my privacy practices, or for additional copies of this Notice, please contact me using the information listed in Section II G of this notice.


A. Permissible Uses and Disclosures without Your Written Authorization

I may use and disclose PHI without your written authorization, excluding Psychotherapy Notes as described in Section II, for certain purposes as described below. The examples provided in each category are not meant to be exhaustive, but instead are meant to describe the types of uses and disclosures that are permissible under federal and state law.

1. Treatment: I may use and disclose PHI in order to provide treatment to you. For example, I may use PHI to diagnose and provide counseling service to you. In addition, I may disclose PHI to other health care providers involved in your treatment.

2. Payment: I may use or disclose PHI so that services you receive are appropriately billed to, and payment is collected from, your health plan. By way of example, I may disclose PHI to permit your health plan to take certain actions before it approves or pays for treatment services.

3. Health Care Operations: I may use and disclose PHI in connection with our health care operations, including quality improvement activities, training programs, accreditation, certification, licensing or credentialing activities. Specifically, if you are a client for whom I file insurance I will need to disclose PHI to ProClaims Medical Management, Inc.-my practice administrator. ProClaims Medical Management is bound by this confidentiality agreement.

4. Required or Permitted by Law: I may use or disclose PHI when I am required or permitted to do so by law. For example, I may disclose PHI to appropriate authorities if I reasonably believe that you are a possible victim of abuse, neglect, or domestic violence or the possible victim of other crimes. In addition I may disclose PHI to the extent necessary to avert a serious threat to your health or safety or the health or safety of others. Other disclosures permitted or required by law include the following: disclosures for public health activities; health oversight activities including disclosures to state or federal agencies authorized to access PHI; disclosures to judicial and law enforcement officials in response to a court order or other lawful process; disclosures for research when approved by an institutional review board; and disclosures to military or national security agencies, coroners, medical examiners, and correctional institutions or otherwise as authorized by law

B. Uses and Disclosures Requiring Your Written Authorization

1. Psychotherapy Notes: Notes recorded by your clinician documenting the contents of a counseling session with you ("Psychotherapy Notes") will be used only by your clinician and will not otherwise be used or disclosed without your written authorization.

2. Marketing Communications: I will not use your health information for marketing communications without your written authorization.

3. Other Uses and Disclosures: Uses and disclosures other than those described in Section I.A. above will only be made with your written authorization. For example, you will need to sign an authorization form before I can send PHI to your life insurance company, to a school, or to your attorney. You may revoke any such authorization at any time.


A. Right to Inspect and Copy. You may request access to your medical record and billing records maintained by me in order to inspect and request copies of the records. All requests for access must be made in writing. Under limited circumstances, I may deny access to your records. I may charge a fee for the costs of copying and sending you any records requested. If you are a parent or legal guardian of a minor, please note that certain portions of the minor's medical record will not be accessible to you.

B. Right to Alternative Communications. You may request, and I will accommodate, any reasonable written request for you to receive PHI by alternative means of communication or at alternative locations.

C. Right to Request Restrictions. You have the right to request a restriction on PHI used for disclosure for treatment, payment or health care operations. You must request any such restriction in writing addressed to the Privacy Officer as indicated below. I am not required to agree to any such restriction you may request.

D. Right to Accounting of Disclosures. Upon written request, you may obtain an accounting of certain disclosures of PHI made by me after April 14, 2003. This right applies to disclosures for purposes other than treatment, payment or health care operations, excludes disclosures made to you or disclosures otherwise authorized by you, and is subject to other restrictions and limitations.

E. Right to Request Amendment: You have the right to request that I amend your health information. Your request must be in writing, and it must explain why the information should be amended. I may deny your request under certain circumstances.

F. Right to Obtain Notice. You have the right to obtain a paper copy of this Notice by submitting a request to the Privacy Officer at any time.

G. Questions and Complaints. If you desire further information about your privacy rights, or are concerned that I have violated your privacy rights, you may contact the Privacy Officer Liza Gellerstedt, LCSW at 675 Seminole Avenue, Suite 210 Atlanta, GA 30307. You may also file written complaints with the Director, Office for Civil Rights of the U.S. Department of Health and Human Services. I will not retaliate against you if you file a complaint with the Director or myself.


A. Effective Date. This Notice is effective on April 14, 2003.

B. Changes to this Notice. I may change the terms of this Notice at any time. If I change this Notice, I may make the new notice terms effective for all PHI that I maintain, including any information created or received prior to issuing the new notice. If I change this Notice, I will post the revised notice in the waiting area of my office. You may also obtain any revised notice by contacting the Privacy Officer.

This Form is educational only, does not constitute legal advice, and covers only federal, not state, law.
( Type Full Name )
Informed Consent and Authorization Form for Liza Gellerstedt, LCSW
Welcome to my practice. There follows some essential information about psychotherapy. Please read and sign at the bottom to indicate that you have reviewed this information.

Length and frequency of treatment: Psychotherapy typically involves regular sessions, usually fifty minutes in length. Duration and frequency vary depending on the nature of your problem and your individual needs.

Confidentiality: Information you share with me will be kept strictly confidential and will not be disclosed without your written consent. By law, however, confidentiality is not guaranteed in life-threatening situations involving yourself or others, in a situation in which children or elders are put at risk (such as sexual or physical abuse or neglect) or if I were to receive a court order to disclose treatment information. If I need to discuss your treatment with a colleague, I will take pains to disguise identifying information, including using a pseudonym. One further caveat to confidentiality is my work with my supervisors, Dr. Karen Schwartz PhD and Dr. Cheryl Eschbach. If I feel it will be helpful to you, I may use my supervision time to gain new perspective on your situation. In the unlikely event that I have a personal emergency, my electronic health records will be released to Megan Tarshis, LCSW so that she may contact you.

Fee policies: My fee for an individual session is $140 for a standard therapy hour of 50-minutes. If you would like an 80-minute initial assessment, I offer a discounted rate of $180 for an 80-minute session at that time. If we find that we are needing more time in treatment, we can discuss scheduling a regular 80-minute session which will be billed at my standard rate of $220. If you need to cancel an appointment, please tell me at least 48-hours ahead of time, otherwise, I may charge you for the missed session. Please be aware that insurance carriers will not cover cancellation charges.

Phone and emergency contact: If you need to contact me by phone, do not hesitate. When I am not available, my voicemail will take a message. I am usually able to return calls within a day. You will not be charged for phone calls unless we have a scheduled conversation of an information-exchanging or problem-solving nature that lasts more than ten minutes. Phone sessions will be indicated as such on receipts and are not generally reimbursed by insurance. If you are experiencing an emergency, you can find emergency services by calling 911, the Georgia Crisis and Access Line (800) 715-4225 or Ridgeview Institute (770) 434-4567.

Physician Contact: Physical and psychological symptoms often interact. I encourage you to seek medical consultation if warranted. In addition, medication may sometimes be helpful for psychological problems. When appropriate, I will arrange a referral for medication evaluation.

Freedom to withdraw: You have the right to end therapy at any time. If you wish, I will give you the names of other qualified psychotherapists.

Informed consent: I have read and understood the preceding statements. I have had an opportunity to ask questions about them, and I agree to enter a professional psychotherapy relationship with Liza Gellerstedt, LCSW.
( Type Full Name )
Payment Policy
Payment for services is an important part of any professional relationship. You are fully responsible for making sure that services are paid in full. As of July 1, 2015, sessions fees are $140 for 50 minute sessions (standard "therapy hour"), $180 for 80 minute sessions (standard "initial assessment") and $220 for an extended session (80-minutes), unless otherwise specified.

It is my policy to keep an authorized credit card on file to be used for all professional services rendered, as well as late cancellations, fees, etc. This prevents you from having a past-due balance. For payment, you may choose to use any credit or debit card with a Visa, MasterCard, American Express or Discover logo. Should your payment be denied for insufficient funds, you will be charged a penalty fee of $25/per incident. You will be given at least 30 days notice in advance if my fees should change. If you miss a session or cancel a session with less than 24 hours advance notice, you shall be charged for the full session fee. Any phone calls lasting longer than 10 minutes will accrue the standard charge of an individual face-to-face session.

All client information, including debit and credit card information, is stored and processed using all the required components for HIPAA compliance. Servers housed in Tier-IV data center with SSAE16, HITRUST, ISO 27001 & PCI 2.0 compliance. PCI (Payment Card Industry) standards applied to our internal systems and software. All traffic is required to use SSL (Secure Socket Layer) with 256-bit encryption. There is a unique login for all users and logging of all user activity. There is a 256-bit encryption of all sensitive data. No sensitive information is sent via email, only notifications to login will be sent. Data is backed up hourly using 256-bit encryption.

By providing your electronic signature, you are agreeing to these terms.
( Type Full Name )