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:

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Is the client covered by insurance?

Client's Relationship to subscriber:

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Secondary Phone:

Primary Insurance Information

Employer:

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Subscriber's Social Security Number:

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Group No:

Policy No:

Secondary Insurance Information

Insurance Company:

Subscriber's Name:

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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.

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