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Register with Allison Lee, M.D.

Welcome to Dr. Lee's registration page. To register as a new patient, please enter your information in the fields below. To set up patient portal access or amend your information, please contact us.

If you are already a registered patient with online access, you can log in here

Basic Contact Information

First Name * Middle Name (or initial) Last Name * Date of Birth * Social Security Number Nickname/Preferred Name Gender *

Your Address

Address 1 * Address 2 City * State/Province * Zip Code *

Contact Information

Mobile Phone Number Home Phone Number Work Phone Number Preferred Contact Number Email Address (Primary) * Secondary Email Address Home Fax Number

Emergency Contact

First Name * Middle Name Last Name * Relationship to Patient Email Address Phone Number *

Insurance Information

Note: I do not bill insurance, but this information makes it easier for me to refer you for other services (like labs or specialists)

Plan Name Group Number Member ID Insurance Type

Medical Information

Please enter your basic medical information below. You may also add or edit this information after you've signed up.

Height (in INCHES) Weight (in POUNDS) Personal Medical History (please also include surgeries and hospitalizations) Relevant Family Medical History (indicate which family member if applicable)

Set Username and Password for Patient Portal

Please create a username and password that you will use to log into the patient portal in the future.

Your username must be at least 4 characters long

Username *

Your password must be at least 8 characters long and include at least one number or special character.

Password * Confirm Password *

The patient portal gives you access to your medical records and lets you securely communicate with your doctors. When you sign up, you will receive an email with instructions for logging in.

"I consent to having medical information sent to my email address (we cannot guarantee the security of messages delivered by email)." "I have read and accept the terms of the privacy policy below:" *

The Notice explains how we fulfill our commitment to respect the privacy and confidentiality of your protected health information. This Notice tells you about the ways we may use and share your protected health information, as well as the legal obligations we have regarding your protected health information. The Notice also tells you about your rights under federal and state laws. The Notice applies to all records held by Allison Lee, M.D.'s facilities and programs, regardless of whether the record is written, computerized or in any other form. We are required by law to make sure that information that identifies you is kept private and to make this Notice available to you.

Your Rights

When it comes to your health information, you have certain rights.

This section explains your rights and some of our responsibilities to help you.

Get a copy of your paper or electronic medical record
- You can ask to see or get an electronic or paper copy of your medical record and other health information we have about you. Ask us how to do this.
- We will provide a copy or a summary of your health information, usually within 30 days of your request. We may charge a reasonable, cost-based fee.
Correct your paper or electronic medical record
- You can ask us to correct health information about you that you think is incorrect or incomplete. Ask us how to do this.
- We may say "no" to your request, but we'll tell you why in writing within 60 days.
Request confidential communication
- You can ask us to contact you in a specific way (for example, home or office phone) or to send mail to a different address.
- We will say "yes" to all reasonable requests.
Ask us to limit the information we share
- You can ask us not to use or share certain health information for treatment, payment, or our operations.
  - We are not required to agree to your request, and we may say "no" if it would affect your care.
- If you pay for a service or health care item out-of-pocket in full, you can ask us not to share that information for the purpose of payment or our operations with your health insurer.
  - We will say "yes" unless a law requires us to share that information.
Get a list of those with whom we've shared your information
- You can ask for a list (accounting) of the times we've shared your health information for six years prior to the date you ask, who we shared it with, and why.
- We will include all the disclosures except for those about treatment, payment, and health care operations, and certain other disclosures (such as any you asked us to make). We'll provide one accounting a year for free but will charge a reasonable, cost-based fee if you ask for another one within 12 months.
Get a copy of this privacy notice

You can ask for a paper copy of this notice at any time, even if you have agreed to receive the notice electronically. We will provide you with a paper copy promptly.
Choose someone to act for you
- If you have given someone medical power of attorney or if someone is your legal guardian, that person can exercise your rights and make choices about your health information.
- We will make sure the person has this authority and can act for you before we take any action.
File a complaint if you believe your privacy rights have been violated
- You can complain if you feel we have violated your rights by contacting us using the information in this notice.
- You can file a complaint with the U.S. Department of Health and Human Services Office for Civil Rights by sending a letter to
  
  200 Independence Avenue, S.W.
  Washington, D.C. 20201
  by calling 1-877-696-6775, or visiting HHS.GOV Complaints .
- We will not retaliate against you for filing a complaint.

Your Choices

For certain health information, you can tell us your choices about what we share.

If you have a clear preference for how we share your information in the situations described below, talk to us. Tell us what you want us to do, and we will follow your instructions.

In these cases, you have both the right and choice to tell us what to share
- Share information with your family, close friends, or others involved in your care
- Share information in a disaster relief situation
- Include your information in a hospital directory
If you are not able to tell us your preference, for example if you are unconscious, we may go ahead and share your information if we believe it is in your best interest. We may also share your information when needed to lessen a serious and imminent threat to health or safety.
In these cases we never share your information unless you give us written permission
- Marketing purposes
- Sale of your information
- Most sharing of psychotherapy notes
In the case of fundraising
- We may contact you for fundraising efforts, but you can tell us not to contact you again.

Our Uses and Disclosures

How do we typically use or share your health information?

We typically use or share your health information in the following ways.

Treat you
- We can use your health information and share it with other professionals who are treating you.
Example: A doctor treating you for an injury asks another doctor about your overall health condition.
Run our organization
- We can use and share your health information to run our practice, improve your care, and contact you when necessary.
Example: We use health information about you to manage your treatment and services.
Bill for your services
- We can use and share your health information to bill and get payment from health plans or other entities.
Example: We give information about you to your health insurance plan so it will pay for your services.

How else can we use or share your health information?

We are allowed or required to share your information in other ways - usually in ways that contribute to the public good, such as public health and research. We have to meet many conditions in the law before we can share your information for these purposes. For more information see: HHS.GOV consumer home .

Help with public health and safety issues
- We can share health information about you for certain situations such as:
  - Preventing disease
  - Helping with product recalls
  - Reporting adverse reactions to medications
  - Reporting suspected abuse, neglect, or domestic violence
  - Preventing or reducing a serious threat to anyone's health or safety
Do research
- We can use or share your information for health research
Comply with the law
- We will share information about you if state or federal laws require it, including with the Department of Health and Human Services if it wants to see that we're complying with federal privacy law
Respond to organ and tissue donation requests
- We can share health information about you with organ procurement organizations.
Work with a medical examiner or funeral director
- We can share health information with a coroner, medical examiner, or funeral director when an individual dies.
Address workers' compensation, law enforcement, and other government requests
- We can use or share health information about you:
  - For workers' compensation claims
  - For law enforcement purposes or with a law enforcement official
  - With health oversight agencies for activities authorized by law
  - For special government functions such as military, national security, and presidential protective services
Respond to lawsuits and legal actions
- We can share health information about you in response to a court or administrative order, or in response to a subpoena

Electronic Access

We provide electronic access to your health information via the MD HQ Patient Portal.

Our Responsibilities

We are required by law to maintain the privacy and security of your protected health information.
We will let you know promptly if a breach occurs that may have compromised the privacy or security of your information.
We must follow the duties and privacy practices described in this notice and give you a copy of it.
We will not use or share your information other than as described here unless you tell us we can in writing. If you tell us we can, you may change your mind at any time. Let us know in writing if you change your mind.

For more information see: HHS.GOV consumer notice .

Changes to the Terms of this Notice
We can change the terms of this notice, and the changes will apply to all information we have about you. The new notice will be available upon request, in our office, and on our web site.

This notice is effective as of 01/29/2020.

"I have read and accept the terms of the Practice Information below"

Practice Information

General Information:

I see clients over the age of 18 for psychiatric consultation, therapy, and medication management. My belief is that the mind and body are strongly connected and that the brain is capable of change. I practice an integrative and collaborative approach to mental health by focusing on healing through diet, self-reflection, lifestyle modification, and medications when needed.

Appointments:

To make or change an appointment, text me or leave a message on my voicemail at (916) 533-1285. There are times when I have made arrangements to come into the office specifically for your appointment. Therefore, appointment changes and cancellations require 24 hours notice or you may be billed for the missed visit.

Please allow up to 1 1/2 hours for your initial consultation. After that, if you would like me to prescribe your medications, you will typically require monthly 45 minute follow-up visits to monitor your progress. Once you are stable on your medications and no longer need adjustments, you may choose to return to your primary care provider or continue to see me. If you choose to have me manage your prescriptions on a long-term basis, I require a minimum of follow-ups every 6 months. This appointment schedule is a general guideline and can vary depending on your individual situation.

I will send an appointment confirmation text the day prior to each appointment. If you do not receive a text from me, please text me to confirm your appointment as sometimes scheduling mistakes can happen.

Fees/Payment/Insurance:

Initial Comprehensive Consultation (90 mins): $350
Follow-up visit (45 minutes): $250
Miscellaneous (extensive reports/letters, lengthy phone contacts): $300/hr

Payment is due at the start of your visit preferably by check or cash. (A $25 fee will be charged for returned checks due to insufficient funds). I accept most credit cards or payment via PayPal in special circumstances. I have not contracted with insurance companies and have opted out of Medicare (therefore, you may not submit any claims to Medicare for your visits). However, if you have private insurance, I can provide you with a receipt which you may submit on your own for reimbursement as allowed by your plan.

Preparing for your first appointment:

There will be a lot of information to cover in your initial visit. In order to make the best use of time, please bring the following to your appointment:

1. A list of PAST psychiatric medications, dosage, response and side effects to the best of your knowledge.

2. A list of all CURRENT medications including over-the-counter medications and vitamins/herbal supplements with dosage and brand name.

3. A copy of recent lab and diagnostic test results

If you will be paying by check, please have it written ahead of time so that we can use our session time for clinical issues.

Sessions will begin and end on time. Therefore, please make every effort to arrive promptly so that your session is not shortened.

Communication/Emergencies:

For non-urgent issues or issues that involve your protected health information, please message me through the secure patient portal. I will return non-urgent messages within 1 business day. Texting to my office phone at 916-533-1285 is most convenient for scheduling purposes such as appointments or cancellations, but I avoid providing clinical advice via text. For more urgent matters, you may text or call me on my personal cell phone at 916-765-3862. However, it could take up to 2 hours for me to return your call. You may also contact me by email at placerpsychiatry@gmail.com but be aware that this is not a HIPAA compliant email account. If you are having an emergency that can't wait up to 2 hours for a response, you should call 911 or go to the emergency room. I never intentionally ignore calls! -- if you have not heard back from me in a reasonable time frame, please contact me again or listen to my voice message for any special instructions as I may be out of town.

Medication Refills:

Submit medication refill requests directly to your pharmacy, even when you have zero refills left. Your pharmacist will then contact me if needed. Note that with many psychiatric medications, stopping abruptly may lead to uncomfortable discontinuation symptoms; therefore, it is important that you call your refill requests into your pharmacy in a timely manner to avoid a last minute rush.

Any information you reveal in your session is confidential and will not be disclosed without your verbal or signed consent. The exceptions are as follows:

• Imminent threats of harm to yourself or inability to care for yourself (provide food, clothing, shelter). I am required by law to reveal this information to others if I deem it necessary to prevent the threatened harm.

• Imminent threats of harm against another person. I am required by law to notify both the intended victim and law enforcement.

• If a court of law subpoenas me to release information, I may be required to provide the information requested by the court.

• If you reveal or I have reasonable suspicion that a child, dependent, or elder has been abused or neglected, I am required by law to report this information to the appropriate government agency.

• If I believe you have a condition in which you should not operate a motor vehicle, I am required by law to inform the appropriate government agency.

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Go to...

Register with Allison Lee, M.D.

Basic Contact Information

Your Address

Contact Information

Emergency Contact

Insurance Information

Medical Information

Set Username and Password for Patient Portal

Get a copy of your paper or electronic medical record

Correct your paper or electronic medical record

Request confidential communication

Ask us to limit the information we share

Get a list of those with whom we've shared your information

Get a copy of this privacy notice

Choose someone to act for you

File a complaint if you believe your privacy rights have been violated

In these cases, you have both the right and choice to tell us what to share

In these cases we never share your information unless you give us written permission

In the case of fundraising

Treat you

Run our organization

Bill for your services

Help with public health and safety issues

Do research

Comply with the law

Respond to organ and tissue donation requests

Work with a medical examiner or funeral director

Address workers' compensation, law enforcement, and other government requests

Respond to lawsuits and legal actions

Electronic Access