NBH Registration

Patient Name*

First NameMiddle NameLast NameSuffix

Date of Birth*

MonthDayYear

Primary Phone Number*

Phone Number Type*

Primary Contact E-mail*

I would like appointment reminders sent to*

EmailTextEmail and textI do not want appointment reminders. Please note we do have a missed appointment fee for no shows if appointments are not canceled with 24-hour notice.

Primary Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

If you are not using insurance for services, please still provide your insurance information incase we are able to use your insurance in the future. If you would still prefer to skip the insurance sections you can write in N/A.

Primary Insurance Name*

Primary Insurance ID #*

Subscriber Name*

First NameLast Name

Subscriber Date of Birth*

Date

Secondary Insurance Name

Secondary Insurance ID #

Subscriber Name

First NameLast Name

Subscriber Date of Birth

Date

Emergency Contact (1)*

First NameLast Name

Relationship*

Contact Phone Number*

Phone Number Type*

Emergency Contact (2)

First NameLast Name

Relationship

Contact Phone Number

Phone Number Type

Office Policies and Procedures

This guide to our office policies and procedures provides answers to frequently asked questions about fees, appointments, insurance and how to contact us. Please read this guide carefully. If you have any questions or concerns, please feel free to contact us at 781-349-2062 or bditullio@norwoodbehavioralhealth.com.

FEES

All fees are billed to third party insurance companies, unless other arrangements have been made. The patient is responsible for the copayment and/or deductible fees. Patients with MassHealth secondary insurance cover the age of 21 will be responsible for copayments.

If your insurance plan changes, please let our office know as soon as possible. Failure to provide a new insurance policy may result in no coverage for a date of service. Dr. Hamoda is only credentialed with Blue Cross and Blue Shield. If you change to another insurance provider you will be switched to direct pay.

PAYMENT OPTIONS

Patients may pay their balance online using the TherapyNotes portal. There is an option to request a sign-up link at the bottom of this form.

Patients may keep a credit card on file. There is the option to add a card to the account at the bottom of this form. Credit cards on file are run once each month for any outstanding balance. A receipt is emailed to the primary email on file. We strongly recommend keeping a credit card on file for streamlined payment.

Patients with no credit card on file will be sent a statement in the mail with any outstanding balance each month. Checks should be made out to Norwood Behavioral Health. Cash or check can be mailed to 100 Morse Street, Suite 220, Norwood, MA 02062.

Patients may call the main line to make a payment over the phone 781-349-2062.

Balances that remain unpaid past 180 days will be sent a final notice letter and may be sent to collections if there is no contact or payment plan established.

MISSED APPOINTMENTS

We require that all appointment changes or cancellations are made at least 24-hours in advance. You can notify your clincian through email or by leaving a message at 781-349-2062. Appointments missed without notice may be charged a $75 missed appointment fee for therapy appointments or a $100 missed appointment fee for psychiatry appointments. If a client consistently no shows or cancels later than 24-hours and/or has missed a total of three appointments, this will constitute grounds for termination.

CONFIDENTIALITY

Psychological services are best provivded in an atmosphere of trust. Because trust is so important, all services are confidential. Nevertheless, we are required by law to make exceptions in certain circumstances, such as when there is suspicion of child abuse, an immediate danger to yourself or others, or other serious occassions.

ROUTINE, NON-URGENT MESSAGES

All clients are asked to contact their provider directly with any routine or non-urgent messages. You can find their email address on our website, www.norwoodbehavioralhealth.com. You can also contact the office at 781-349-2062 or email bditullio@norwoodbehavioralhealth.com. Please allow 24-48 hours for a response, as some of our providers only in the office part time.

EMERGENCY MESSAGES AND TELEPHONE CALLS

Norwood Behavioral Health offers outpatient therapy and psychiatry services. We do not have an on-call provider or emergency staff. In an emergency, all clients are instructed to call 911 or visit the closest hospital emergency room.

Riverside Community Services offers crisis support as an alternative to a hospital emergency room:

Milford and the Surrounding Communities: 800-294-4665

South and West of Boston: 800-529-5077

Southbridge and the Surrounding Communities: 877-750-3127

By signing below, I have reviewed and agree to the above policy and procedures.

Signature*

Clear

Name*

First NameLast Name

Date*

Date

Credit Card on File Form (Recommended)

At Norwood Behavioral Health, we request keeping your credit or debit card on file as a convenient method of payment for the portion of services your insurance doesn't cover, but for which you are liable, including missed appointment fees. We will email you a receipt when a payment is made.

Your credit card information is kept confidential and secure. Deductible, co-insurance, or other uncovered fees are processed after the claim has been filed and processed by your insurer, and the insurance portion of the claim has been paid and posted to the account. Patients using insurance are run for payment each month. Patients who are paying out-of-pocket are processed biweekly on Thursdays.

I authorize Norwood Behavioral Health to charge the portion of my bill that is my financial responsibility to the following credit or debit card.The authorization relates to all payments not covered by my insurance company for services provided to me by Norwood Behavioral Health.

This authorization will stay in effect until I cancel this authorization. To cancel, or for any billing questions, please email bditullio@norwoodbehaviorallhealth.com.

*

I would like to add a card on file (enter information below). You will not receive a billing statement in the mail. A receipt will be emailed to the primary address on file.I do not want to add a card on file and choose to pay another way (cash, check, or online payment through the TherapyNotes portal). Cash or check can be mailed into the office or left at the front desk. Checks should be made out to Norwood Behavioral Health. You will receive a billing statement in the mail every month if you do not have a card on file.

Is this card an HSA or Flex Spending Account?*

YesNo

Please enter last four digits of the card for security reasons. We will call you to confirm the full number.

MM/YY

CVV

Signature

Clear

Name

First NameLast Name

Phone Number

We will call this number to confirm your full card number.

Date

If you do not want to add a card on file, TherapyNotes has a portal to pay your balance online on your own. If you would like us to send a link to sign up, please let us know which email to use. You will receive a welcome email from TherapyNotes to create an account attached to the email address. You may keep a card on file AND have access to the portal.

example@example.com

Registration Packet