NBH Registration

Patient Name*

First NameMiddle NameLast Name

Date of Birth*

MonthDayYear

Primary Phone Number*

Format: (000) 000-0000.

Phone Number Type*

Primary Contact E-mail*

This email address will receive a link to join our patient portal. Only one email address can be linked to the portal at this time. The portal is primarily used for billing purposes.

Phone Number & Email Contact Relationship to Patient*

Mother, Father, Self, etc.

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. You can unsubscribe from these reminders at any time.

Patient's 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 in case 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*

Format: (000) 000-0000.

Phone Number Type*

Contact Email

example@example.com

EmailTextEmail and textNo reminders

Emergency Contact (2)

First NameLast Name

Relationship

Contact Phone Number

Format: (000) 000-0000.

Phone Number Type

EmailTextEmail and textNo reminders

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.

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.

BILLING & PAYMENTS

All fees are billed to third party insurance companies, unless other arrangements have been made. The patient is responsible for understanding their insurance policy and any copayments or dedutible fees they may owe. The patient is responsible for paying these fees in a timely manner.

Paying Out-of-Pocket

If you are paying out-of-pocket for services, we would please ask you keep a card on file by completing the Payment Authorization Form on the portal. We will send you a No Surpises Act Agreement Form with our current rates.

Old Balances

The practice will send a final notice letter to accounts that are at least 120+ days old requesting payment or a payment plan be established. Failure to pay your balance after receving a final notice letter will result in your account being forwarded to collections. The final notice letter will reiterate there will be a 30% collection fee added to your balance if there is no contact to the office and/or payment is not made by the set due date. This fee is the patient responsibilty and will be collected by our collections attorney.

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

INSURANCE CHANGES

If your insurance plan or ID number changes, please alert the office as soon as possible. Claims rejected due to not having the correct insurance may result in the patient's reponsiblity. Failure to provide a new insurance policy may result in no coverage for a date of service.

We are accepting THESE PLANS. There may be some variation amongst our clinicians in who can accept what insurance plan. Please check with us if you have any questions about coverage.

INTAKE EVALUATION & APPOINTMENTS

The first session at our practice a 60-minute intake evaluation. If after this session, we feel that your needs are beyond the scope of our practice, we will provide resources to an appropriate clinician and/or facility outside of our practice.

It is recommended parent(s) attend the first session for clients under age 18.

For the intake session and subsequent appointments, if your child is under the age of 18, please remain in the waiting room or on-site for the duration of your child's visit unless previously discussed with your clinician.

MISSED APPOINTMENTS

We require that all appointment changes or cancellations are made at least 24-hours in advance. You can notify your clinician 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.

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 contact your provider directly via the TherapyNotes patient portal. There is a link at the top right corner of our website to access this portal, or you can use the link: https://www.therapyportal.com/p/nbh02062/.

Medication refills should be sent via the TherapyNotes portal. Please allow three business days for the request to be completed.

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 are part-time.

We do not have a traditional front desk, and our office line is a voicemail box. The mailbox is monitored throughout the day, and calls are returned as soon possible during business hours.

THERAPYNOTES PORTAL

Upon scheduling your first session, you will receive an email from TherapyNotes to join our patient portal. This will allow you to:

View your upcoming appointments
View your most recent billing statement
View your account balance
Make one-time payments
Add a card to your account by completing the Payment Authorization Form
Complete any questionnaires shared to the portal by your clincian
Send messages (biling, general, to your clincian, med refill requests, etc.)

You must have a portal account to receive billing statements. If your link to join expires, please contact bditullio@norwoodbehavioralhealth.com for a new link.

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

Signature*

Name*

First NameLast Name

Date*

Date

Payment Options

BILLING STATEMENTS

Billing statements are sent quarterly via the portal to patients who do not have a card on file. You will receive an email alerting you there is a new document for your review in your portal account. Your portal balance will always be up-to-date and payments can be made at any time.

CREDIT CARD ON FILE - PAPERLESS, RECOMMENDED

Patients may keep a credit card on file. Credit cards are run automatically after sessions occur, and/or after we receive payment from your insurance with indication of any deductible or coinsurance responsibility.

We recommend keeping a credit card on file for streamlined payment.

To add a card, please complete the Payment Authorization Form on your portal account under the Documents tab. Receipts can be found in the Billing tab on the portal.

If you have not received a link to sign-up for the portal or it has expired, please email bditullio@norwoodbehavioralhealth.com or your clinician for a new link.

You may request an itemized billing statement of sessions with payments made at any time by emailing bditullio@norwoodbehavioralhealth.com.

ONE-TIME PORTAL PAYMENTS

Patients may make one-time payments on the portal under the Billing tab. Your account will always display the active total amount due to the account, but you are able to make payments of any amount via the portal. Receipts can be found in the Billing tab on the portal.

If you have not received a link to sign-up for the portal or it has expired, please email bditullio@norwoodbehavioralhealth.com for a new link.

CHECKS

Checks should be made out to Norwood Behavioral Health and mailed to 115 Norwood Park South, Suite 110, Norwood, MA 02062. If you are seen in-person, you may leave a check with the front desk.

PHONE

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

OVERDUE BALANCES

Balances that remain unpaid past 120 days+ will be sent a final notice letter. Accounts may be forwarded to our collections attorney if there is still no contact by the due date noted on this letter.

Accounts that receive a final notice letter will be asked to keep a card on file for future services. Unpaid balances may result in pause in treatment until a payment is made.

I understand the above payment options and policies. I would like to add a card to my account (please complete the Payment Authorization Form on the portal).I understand the above payment and policies options. I do not want to add a card to my account and choose to pay another way (check, over the phone, or one-time payments through the portal).

Signature

Name*

First NameLast Name

Date

Registration Form