Community Wellness Partners of NC PLLC
809 N. Lafayette St., Suite A, Shelby, NC 28150
1446 E. Gaston St. Suite 101, Lincolnton, NC 28092
Phone: (704) 284-0554
Email: info@cwpofnc.com
BILLING AND INSURANCE
INFORMATION
Patient's Name:
Name:
Social Security Number:
Is this person a client here?
No
Yes
Is the client covered by insurance?
Yes
No
Client's Relationship to subscriber:
Birth Date:
Address:
City:
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Primary Insurance Information
Employer:
Occupation:
Employer Phone:
Insurance Company:
Subscriber's
Name on Insurance Card:
Subscriber's
Social Security Number:
Subscriber's Birth Date:
Group No:
Policy No:
Secondary Insurance Information
Insurance Company:
Subscriber's Name:
Client's relationship to Subscriber:
Group No:
Policy No:
The above information is true to the best of my knowledge. I authorize my insurance benefits be paid directly to
Community Wellness Partners of NC PLLC dba
Shelby Wellness and Therapy Center.
I understand that I am financially responsible for any balance on my account. I also authorize
Community Wellness Partners of NC PLLC dba
Shelby Wellness and Therapy Center or insurance company to release any information required to process my claims.
If you have Medicaid it is your responsibility to provide primary insurance information. If you fail to provide primary insurance, you will be responsible. Medicaid will not pay.
Client/Guardian Signature:
(use finger or mouse on box to sign)
Signature Date: