Well BH- New Client Registration Form

New Client Registration Form

Thank you for completing our registration form. Completion time about 10 min.
Today's Date

MonthDayYear
Date
Client's Name*

First NameLast Name
Client DOB*
Phone Number*

Area CodePhone Number
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email*
example@example.com
Parent or Guardian's Name

First NameLast Name
Emergency Contact Information
Emergency Contact*

First NameLast Name
Emergency Contact Phone Number*

Area CodePhone Number

Client Agreements
I attest that I have requested mental health services with Well Behavioral Health, LLC (WBH). Please check the appropriate selection:*

I will utilize my health insurance for service. I authorize the office of WBH to bill my health insurance carrier on my behalf.
For Blue Cross Blue Shield Clients only:

I understand that I may be seen by a Master’s level clinician seeking independent licensure at WBH. I have been informed that I have the option to wait to see an independently licensed clinician and I am choosing to be seen by a Master’s level clinician seeking independent licensure at WBH instead.
My initials indicate agreement:
NOTICE OF PRIVACY PRACTICES

IBC's “Notice of Privacy Practices” is available to review below, and is also available at www.thewellbh.com. I am aware that I can also ask my clinician for a paper copy. I understand that I may ask questions about the information outlined in the Notice at any time in the future.
COMMUNICATION CONSENT

I give permission to WBH to contact me at the phone number(s) or email listed on this Client Registration Form. If I am not available, I authorize WBH to leave a message on my voicemail. My signature below indicates that I am aware that the “Electronic Communication Policy” is available for my review at www.thewellbh.com. I am aware that I can ask my clinician for a paper copy.

Well Behavioral Health LLC- Office Polices
Telephone / Email Communication: Telephone and email communication with your clinician is not covered by insurance. There is no charge for brief, routine phone calls or emails (less than 10 minutes) between a client and their clinician to discuss scheduling, billing, or brief progress updates. However, longer correspondences between a client and clinician, as well as all collateral correspondences, will be billed at a rate of $30 per 15 minutes. This fee also applies to all paperwork clinician’s complete on behalf of clients.

I Agree
Cancellations / No-Shows: A 24-hour advance notice is required for all cancellations. No-shows and late cancellations (less than 24-hour notice) will result in a fee of $90 which is payable before subsequent sessions can be scheduled. This is not a fee covered by insurance.

I Agree
Payment Policy: All session payments and copayments are to be made at the time of each visit. Clients seeking treatment at WBH will need to have a credit card on file for all out-of-pocket costs. In the event that there is an account balance, statements will be sent out at the end of each month. Payment in full is due within 30 days unless an alternate agreement is made in advance. All delinquent accounts will be sent to collections.

I Agree
Insurance: Notify us immediately of any changes to your health insurance coverage. It is your responsibility to keep your medical insurance information updated. Clients will be responsible for paying all claims that are not reimbursed by their insurance company due to changes to, or termination, of their policy. WBH does not submit secondary insurance claims, or Worker’s Compensation claims.

I Agree
Additional Services: Any case consultation meetings that your provider attends on your behalf (either in person or via video chat) are generally not covered by insurance. All meetings will be billed at a rate of $100 per 30-minute block. The billing charges will also apply to travel time and preparation time as needed.

I Agree

Insurance Card

Please help us ensure that all your insurance claims are processed properly. Send us a photo of the front and back of your insurance card. Please try to get the insurance card centered evenly in the screen.
Front of Insurance Card*
Back of Insurance Card*
ID Card

Please take a picture of your ID card. If the client is under underage, we require the legal guardian's ID card.
ID Card*

Credit Card Authorization / Billing Form

All session copayments and deductibles are due at the time of service. WBH only accepts credit card payments for client’s out-of-pocket expenses.
I authorize WBH to automatically bill the credit card I provided for my co-payment / co-insurance and/or deductible responsibilities, any out-of-pocket payments, and/or denials not covered by my insurance. I understand that I am responsible for the patient portions outlined by my insurance provider.*

I agree
I authorize WBH to bill this credit card for any missed session fees incurred per our office's missed session policy.*

I agree
I acknowledge that all client payments are due at the time of session*

I agree
Signature Page

Thank you for completing this form. Please use your mouse, stylus, or finger to sign below.
Name of person signing the registration form*

First NameLast Name
Relationship to the client*
Signature*
Should be Empty:

New Client Registration Form

Emergency Contact Information

Client Agreements

Well Behavioral Health LLC- Office Polices

Insurance Card

ID Card

Credit Card Authorization / Billing Form

Signature Page