NBH Registration

Patient Name *

First Name Middle Name Last Name Suffix

Date of Birth *

Month Day Year

Primary Phone Number *

Phone Number Type *

Primary Contact E-mail *

I would like appointment reminders sent to *

Email Text Email and text I 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

City State / 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 Name Last Name

Subscriber Date of Birth *

Date

Secondary Insurance Name

Secondary Insurance ID #

Subscriber Name

First Name Last Name

Subscriber Date of Birth

Date

Emergency Contact (1) *

First Name Last Name

Relationship *

Contact Phone Number *

Phone Number Type *

Emergency Contact (2)

First Name Last 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 781-762-1419 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. We do not have an online payment system established. Patients with no credit card on file be sent a statement in the mail with any outstanding balance. Patients with credit cards on file are run the first full week of 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. Balances that remain unpaid past 120 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 781-762-1419. 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, 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 immeidate 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 781-762-1419 or email bditullio@norwoodbehaivioralhealth.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 *

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Name *

First Name Last 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 mail or 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 the first full week of each month. Patients who are paying out-of-pocket are processed on Thursdays every two weeks.

I authorize Norwood Behavioral Health to charge the portion of my bill that is my fianancial 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@norwoodbehaivoralhealth.com.

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

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Name

First Name Last Name

Phone Number

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

Date

Registration Packet