NBH Registration

Patient Name*

First NameMiddle NameLast Name

Date of Birth*

MonthDayYear

Primary Phone Number*

Phone Number Type*

Primary Contact E-mail*

This email address will receive a link to join our patient portal.

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.

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. Dr. Hamoda is only contracted with Blue Cross and Tufts at our practice. Please keep this in mind if your insurance changes to another plan.

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*

Name*

First NameLast Name

Date*

Date

Payment Options

CREDIT CARD ON FILE - PAPERLESS, RECOMMENDED

Patients may keep a credit card on file. Credit cards are run the first week of the month for the balance on the account. We strongly 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 for a new link.

ONE-TIME PORTAL PAYMENTS

Patients may make a one-time payment on the portal under the Billing tab. You will also receive a monthly statement in the mail alerting you to any balance. Your account will always display the current amount due to the account. 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

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 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 180 days will be sent a final notice letter and may be sent to collections if there is no contact and payment plan established. Accounts that receive a final notice letter will be asked to keep a card on file. Unpaid balances may result in pause in treatment until a payment is made.

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

Signature

Name*

First NameLast Name

Date

Registration Packet