NSTMS - New Patient Registration Form

DateTime
Patient's Full Name *

First Name Last Name
Patient's Preferred Name *
Patient's Address *

Street Address

Street Address Line 2

City State

Zip Code
Patient Date of Birth (we see ages 14 and up only) *

Month Day Year
E-mail Address for patient or person arranging appointment *
2nd email - family member or emergency contact
example@example.com
Can we use your email to communicate with you (including email reminders)? *

YES NO
Patient or Parent/Guardian's Mobile Number *

Area Code Phone Number
Can we use your Cell or Mobile Number to communicate with you (including text reminders and text communication)? *

YES NO

Welcome and thank you for seeking out information about the NeuroScience & TMS Treatment Centers.

As you begin this process, read this letter. You will be asked to sign below stating that you have read it.

When you are selecting a clinician to see in the office, note that our clinicians are in different insurance networks. We are presently trying to get all clinicians on the same contracts.

Verify below in the appointment selection section and also with the office staff who books your appointment. Make sure you are scheduled with the clinician with which you wish to be booked and that you understand if they are out-of-network or in-network with your insurance company.

You can use out-of-network coverage benefits (if your insurance allows) with other insurance policies by requesting a statement of service and your bill.

We are NOT In-network with Medicare nor TNCare.

We cannot bill for services with Medicare nor TNCare. Please Note that BCBS, Anthem, United, Optum, and Cigna manage some Medicare policies: if your policy is a Medicare or Medicaid policy, managed by one of these companies, then we are NOT in your network.

The therapists associated with the clinic are NOT on any insurance panels, they are "out of network" with any insurance companies and charge private rates.

   _______________________________________________

This is the beginning of the 3 Step Enrollment process to become a patient. In our clinic, we care for patients age 14 and up.

The application should take 10-20 minutes depending on your personal speed with these types of electronic forms. If you don't have time to finish you can save the form and return it later to complete it by pressing "SAVE and CONTINUE Later."

STEP 1: Complete this private, HIPAA-compliant questionnaire and select a service. Complete the Insurance Section* so that we can file in-network claims & so you understand what and how your insurance will pay.

*If you want us to submit the claim to your insurance, you will need an electronic copy/photo of the subscriber's insurance card (front & back) while completing this form. You will also need an electronic copy/photo of your driver's license to complete the application.

STEP 2:  Read and agree to all office policies AND Pay the new appointment deposit**

**The new appointment deposit covers part of the fee for the potential of a Missed Appointment, or Late Cancellation as our clinicians set aside significant time for the new patient appointment. Insurance does not cover missed appointments or Late Cancellations, see the policies below. If you come to your scheduled appointment and your insurance covers your visit fees, we will reimburse (or credit your account) for any amount which you may have overpaid.

STEP 3: Prior to your initial appointment, you will receive emails to complete a Medical History questionnaire, assessments, and releases, these are essential to your initial visit. If you don't complete the Medical History you will be asked to do it at the first appointment.

______________________________________________

We look forward to helping you with the process of reaching wellness.

If you have questions about the process, email Brogan Allen, support@hopeforyourbrain.com.
I have read the information above & understand the process to get a new patient appointment. If I need more information I can email support@hopeforyourbrain.com OR call, 615-224-9800 *

Clear
Full name of adult signing above *

First Name Last Name

STEP 2: Complete the Insurance Section

Our psychiatric Nurse Practitioners are in-network with many insurances at NeuroScience & TMS Treatment Centers (unfortunately therapist is not in-network). If you have other insurance you may have out-of-network benefits. You will need to send a copy of the FRONT/BACK of the insurance card and a copy of the DRIVER's LICENSE. If there is no insurance write, "NONE"
Is the patient covered by a BCBS, Anthem, Cigna, United Healthcare or Optum insurance policy? *

YES NO
Name of Insurance Policy (for example: BCBS, Anthem, Optum, Beacon, Tricare, Aetna, etc) *
The Insured Subscriber's POLICY ID Number? *
Write None if private paying
The Insured Subscriber's Group ID Number? *
Write None if private paying
What is the Name of the Subscriber (who's name is on the insurance policy, if not the patient)? *
Write the word NONE, if you are privately paying for the charges
What relation is the Subscriber to the patient? *
Write-in Myself/ Parent/ Spouse/ Guardian/ or other
What is the Date of Birth of the Subscriber? *
If we are not filing insurance, write 00/00/0000
Give us the Insurance Subscriber's Address (if the same as the patient's address, just write "same as patient's address above"). If private paying, write "NONE" *
Please attach a copy of the FRONT & BACK of your insurance card & a copy of your driver's license with this form.

If you lack the technology to do this, please email support@hopeforyourbrain.com or call 615-224-9800, and we can discuss other ways you could send or drop off your information.
UPLOAD the FRONT of the Patient's Insurance Card

Browse Files

Cancel of
UPLOAD the BACK of the Patient's Insurance Card

Browse Files

Cancel of
UPLOAD a copy of the patient's or responsible parties drivers license

Browse Files

Cancel of

Health Insurance does not cover all potential fees. If we are filing insurance for in-network charges, your insurance requires you to complete the following three (3) acknowledgments.

READ all three (3) statements & sign below to acknowledge that you have read and understood your responsibilities. If you are paying privately or are using insurance as an out-of-network service, then you are not required to sign below. If this is the case, write Not Applicable in the signature line)
1) ACKNOWLEDGMENT OF NON-COVERED CHARGES

Re (Identification of Prescribed Service): Charges for a Virtual visit, phone call or phone call session which is outside office hours (Emergent or Urgent calls)
Select your insurance company which manages Mental Health benefits *
If your insurance company is not listed, please type the name here:
Select the form that corresponds with your insurance company *
Most insurance companies are covering virtual (phone & video) sessions presently. Legally you must be in Tennessee to receive services from our clinicians.

Even though these visits are generally covered, I have been informed that my health care benefits insurer or administrator may determine that the above-referenced service(s) may be an Investigational Service, Cosmetic, may not be a Covered Service or may not be Medically Necessary or Medically Appropriate as those terms are defined in my Member health care benefits plan. Therefore, the service would be excluded from coverage by my health care benefits plan. My provider has also informed me about alternative treatments, if any, that may be covered by my insurance company.

I understand that my provider may request that my insurance reconsider that determination by presenting evidence that the referenced service(s) is not an Investigational Service, is a Covered Service or the service is considered to be Medically Necessary or Medically Appropriate. I also understand that I have the right to request reconsideration of that determination, as described in the Member grievance section of my health care benefits plan, either before or after receiving the service(s) I have been informed that the potential costs of the referenced service(s) will be approximately $100 per 10 minutes for a phone call or video session when completed emergently or urgently outside a clinician's scheduled hours. I understand that, if I elect to receive the service(s) and my insurance company determines that the service(s) 1) is an Investigational Service, 2) is not a Covered Service or 3) the service is not considered to be Medically Necessary or Medically Appropriate, I will be responsible to pay for all costs associated with the service(s), including, but not limited to, practitioner costs, facility costs, ancillary charges, and any other related expenses. I acknowledge that my insurance may not pay for the service(s

In the event of multiple procedures, this form is valid only for one (1) unit of the prescribed service(s), unless specifically provided for otherwise.

This form shall be active while I am under the care of a clinician at the NeuroScience & TMS Treatment Centers.
By signing below I am acknowledging that I have read and agree with the Acknowledgment of Non-Covered charge Policies. I have been told in-advance by my clinician that the services/products listed above are not covered by my Health Plan. I agree to pay for these non-covered services. *

Clear
Patient Name, if 18 or older, or Custodial Parent or Guardian (if patient is under 18 years old) *

First Name Last Name
2) ACKNOWLEDGMENT OF NON-COVERED CHARGES

Re (Identification of Prescribed Service): Charges for Missed Appointments or Late Cancellations (failure to keep a scheduled appointment or notify us to cancel with 3 business days' notice).
I have been informed that my health care benefits insurer or administrator may determine that the above-referenced service(s) may be an Investigational Service, Cosmetic, may not be a Covered Service or may not be Medically Necessary or Medically Appropriate as those terms are defined in my Member health care benefits plan. Therefore, the service would be excluded from coverage by my health care benefits plan. My provider has also informed me about alternative treatments, if any, that may be covered by my insurance coverage.

I understand that my provider may request that my insurance company reconsider that determination by presenting evidence that the referenced service(s) is not an Investigational Service, is a Covered Service or the service is considered to be Medically Necessary or Medically Appropriate. I also understand that I have the right to request reconsideration of that determination, as described in the Member grievance section of my health care benefits plan, either before or after receiving the service(s),

I have been informed that the potential costs of the referenced service(s) will be approximately $120 for a 20-30 minute follow-up session with a Nurse Practitioner, or $200 for an hour session with a Nurse Practitioner, or $250 for a 30min follow up, or $350 for an hour follow-up session with a Medical Doctor. I understand that, if I elect to receive the service(s) and my insurance determines that the service(s) is an Investigational Service, is not a Covered Service or the service is not considered to be Medically Necessary or Medically Appropriate, I will be responsible to pay for all costs associated with the service(s), including, but not limited to, practitioner costs, facility costs, ancillary charges, and any other related expenses. I acknowledge that my insurance may not pay for the service(s

In the event of multiple procedures, this form is valid only for one (1) unit of the prescribed service(s), unless specifically provided for otherwise.

This form shall be active while I am under the care of a clinician at the NeuroScience & TMS Treatment Centers.
By signing below I am acknowledging that I have read and agree with the Acknowledgment of Non-Covered charge Policies. I have been told in-advance by my clinician that the services/products listed above are not covered by my Health Plan. I agree to pay for these non-covered services now in preparation of my new patient appointment *

Clear
Patient Name, if 18 or older, or Custodial Parent or Guardian (if patient is under 18 years old) *

First Name Last Name
3) ACKNOWLEDGMENT OF NON-COVERED CHARGES

Re (Identification of Prescribed Service): Clinical work outside of session including electronic Prescription Refills and other related work either electronic, email, and/or paperwork.
I have been informed that my health care benefits insurer or administrator may determine that the above-referenced service(s) may be an Investigational Service, Cosmetic, may not be a Covered Service or may not be Medically Necessary or Medically Appropriate as those terms are defined in my Member health care benefits plan with my insurance. Therefore, the service would be excluded from coverage by my health care benefits plan. My provider has also informed me about alternative treatments, if any, that may be covered by my insurance.

I understand that my provider may request that my insurance reconsider that determination by presenting evidence that the referenced service(s) is not an Investigational Service, is a Covered Service or the service is considered to be Medically Necessary or Medically Appropriate. I also understand that I have the right to request a reconsideration of that determination, as described in the Member grievance section of my health care benefits plan, either before or after receiving the service(s).

I have been informed that the potential costs of the referenced service(s) will be approximately $30 for a prescription refill outside of a session, or other related clinical work prorated accordingly to the length of time at $40 per 10 minutes. I understand that, if I elect to receive the service(s) and my insurance determines that the service(s) is an Investigational Service, is not a Covered Service or the service is not considered to be Medically Necessary or Medically Appropriate, I will be responsible to pay for all costs associated with the service(s), including, but not limited to, practitioner costs, facility costs, ancillary charges, and any other related expenses. I acknowledge that my insurance may not pay for the service(s).

In the event of multiple procedures, this form is valid only for one (1) unit of the prescribed service(s), unless specifically provided for otherwise.

This form shall be active while I am under the care of a clinician at the NeuroScience & TMS Treatment Centers.
By signing below I am acknowledging that I have read and agree with the Acknowledgment of Non-Covered charge Policies. I have been told in-advance by my clinician that the services/products listed above are not covered by my Health Plan. I agree to pay for these non-covered services. *

Clear
Patient Name, if 18 or older, or Custodial Parent or Guardian (if patient is under 18 years old) *

First Name Last Name

STEP 3: REVIEW POLICIES & PAY THE DEPOSIT Please review all office policies on our website (Privacy Policies, General Office Policies, and Insurance & Payment Policies).

Please read and check that you understand each of the individual policies on www.hopeforyourbrain.com. If questions, email us, support@hopeforyourbrain.com.
The policies, below, are highlighted for emphasis:

****Read ALL the Policies (Privacy, General Office, and Insurance & Payment Policies), on the website, www.hopeforyourbrain.com, then sign below.****

Late Cancellation/Missed Appointment Policy

Notification must be received by 4:00 pm CDT, three (3) business days before the scheduled appointment in order to avoid charges.

If you have to cancel or reschedule my new patient appointment, you must give three (3) business days' notice prior to the date of the appointment in order to receive a full refund. A large block of time is booked for the new appointment, and we must have a 72-hour (three business-day) notice in order to potentially reschedule the time. If you cancel the new patient psychiatric appointment or miss this appointment, you will be responsible for the full-fee ($395) and this can not be billed to insurance. We will use your deposit for part of this late cancellation/missed appointment but you will still owe $220, (total charge $395 - deposit $175 = Remaining balance of $220).

The initial therapy appointments are $250 and are not in-network charges. We require a full deposit for new therapy appointments. If you cancel the new therapy appointment with less than three business days' notice or miss this appointment, you will be responsible for the full-fee ($250). We will use your deposit for the late cancellation or missed appointment.

For all follow-up appointments, we also have a 72-hour cancellation policy. If you miss an appointment OR do not cancel with a three (3) business-day notice, you will be obligated to pay the full fee of the service. For example, the Late cancellation or missed Nurse Practitioner session/30-minute appointment would cost $120/a late cancel or missed Nurse Practitioner session/30-minute appointment would cost $200.

Again, Late Cancellations and Missed Appointment fees are not covered by insurance.

Prescription Refill Policy

The policy in the office is to refill all medication within an appointment, and because of this we generally, do not prescribe medication outside office visits.

Medication refills are handled during office hours, during scheduled appointments, when an assessment can be made of the patient. We refill medications only for patients currently under our care.

If you are prescribed medication, you will be given enough medication to cover you until your next scheduled appointment. If you have to cancel please reschedule quickly to avoid running out of medication. Contact us directly if you need a refill of prescribed medication, and allow 72 hours for refills to be sent.

Prescription refills outside of an office visit will be charged $30. This fee is not billable to your insurance.

If your appointment is rescheduled because of unforeseen circumstances, on our part, there will not be a charge.

Payment of Charges Policy

All charges must be paid at the time of service. The office staff will collect for the booked amount of time with the Clinician (or co-pay and deductible if applicable).

You are agreeing to allow Neuroscience & TMS Treatment Centers (NS-TMS) to charge the credit card on file for any fees due that are outstanding following the appointment or outside of an appointment.

The following are a few common examples of when this might happen:

• If you have insurance coverage for your appointments and we incorrectly collected a lower estimated co-pay, co-insurance, and/or deductible, and then later receive an Explanation of Benefits (EOB) from your insurance showing that we did not collect enough money from you, then we will notify you and charge the balance to your card on file.

• If your appointment goes beyond the originally booked time, then the clinician will bill for the additional amount of time in the session, and this could mean that you might have a larger charge than you paid when you arrived for the appointment.

• The clinicians charge their hourly rate for any service on your behalf (letter writing, review of medical records, calls to outside therapists/or clinicians caring or you, review of labs/tests, completing special insurance forms, emergency call after hours, refills outside of your appointment, late cancellations/no-show charges, etc.).

Likewise, if we overcharge you, we will immediately apply the credit to your account. If you prefer, notify us and we can refund the charge.
By signing below, I am acknowledging that I have read all of the policies on the NeuroScience & TMS Treatment Centers website.

I agree to my cardholder policy and I authorize the deposit selected by me, as well as, all outstanding fees, non-covered fees, and late cancellations or missed appointment fees to be charged to my credit card as explained in the Insurance & Payment policies and the General Office policies.

I have read & agreed to all policies of the NeuroScience & TMS Treatment Centers (Privacy, General Office, and Insurance & Payment) and any and all of those policies that may be amended and published on www.HopeForYourBrain.com.
Signature of Patient or the financially responsible adult (as noted below): *

Clear

Deposit for New Appointment *

Deposit - New Appointment w/ Physician $ 175.00

Dr Becker will set aside 60 minutes for a new patient apppointment. If you do not show or cancel late for the appointment, this deposit will cover part of the charge. $320 will be due by you in this case: $495-175 (deposit) = $320. If you come to your scheduled appointment and your insurance covers your visit fees, we will reimburse (or credit your account) for any amount which you may have overpaid with the deposit.

Deposit - Physician Consultation for TMS or Spravato $ 175.00

A Physician will set aside 60-90 minutes for a thorough consultation. If you do not come to your appointment insurance will not cover the no-show/missed rate and you will owe $175 more ($350-$175 deposit = $175). If you come to the appointment, this deposit will be applied for any co-payments, co-insurance, or deductible. We will reimburse (or credit your account) for any amount overpaid by your deposit.

Deposit - New Appointment w/Psychiatric Nurse Practitioner $ 175.00

Our clinicians set aside significant time for your new patient appointment (90 minutes). If you do not show or cancel late for the new appointment, this deposit will cover part of your psychiatric charge. Initial psychiatric visit charge $395 - $175 (deposit) = $220 will be owed (if the appointment is missed/late cancel). If you come to your scheduled appointment and your insurance covers your visit fees, we will reimburse (or credit your account) for any amount which you may have overpaid with the deposit. See below for the therapy appointment description.

Deposit - New Appointment with Therapist $ 250.00

Therapy appointments in the office are not covered by insurance as the therapist is out of network. The charge for the initial appointment with the therapist is 250.00 per 90 minutes. If you miss your appointment or cancel late you will be charged for the full $250.00 charge. Your deposit covers the first therapy appointment.

Total $ 0.00

Credit Card Details
First Name	Last Name
Credit Card Number	Security Code
Card Expiration

Should be Empty:

Step 1: Complete Questionnaire & Select Service

Minor or Ward Consent Form

Give us some information about you (the patient) in the following questions.

If you would you like a FREE Screening Consultation with the Care Coordinator, to see if TMS or Esketamine is right for you, call, 615-348-8200 - No appointment, and no deposit is needed for this Screening visit.

STEP 2: Complete the Insurance Section

Please attach a copy of the FRONT & BACK of your insurance card & a copy of your driver's license with this form.

1) ACKNOWLEDGMENT OF NON-COVERED CHARGES

2) ACKNOWLEDGMENT OF NON-COVERED CHARGES

3) ACKNOWLEDGMENT OF NON-COVERED CHARGES

STEP 3: REVIEW POLICIES & PAY THE DEPOSIT Please review all office policies on our website (Privacy Policies, General Office Policies, and Insurance & Payment Policies).