IN NETWORK:
Community Wellness Partners of NC PLLC dba Shelby Wellness and Therapy Center(SWTC) is in-network with Aetna, BCBS, Carolina Behavioral Health Alliance, Healthgram, Magellan, MedCost, NC Medicaid, NC HealthChoice, Optum, StarMark, UMR, and United HealthCare. SWTC will file insurance claims on behalf of clients who hold policies with these networks, with the express understanding that if reimbursement is not received within 60 days of the date of service, balance will be due in full, or may begin to incur a 1.5% interest charge, retroactive to the date of service.
By signing below, you are requesting that SWTC file claims with Aetna, Carolina Behavioral Health Alliance, Magellan, or MedCost on your behalf and hereby assign payment directly to SWTC for benefits, if any, otherwise payable to you for services rendered, but not to exceed the reasonable and customary charges for those services.
You further authorize SWTC to release to your insurance company any protected health information acquired in the course of your examination or treatment for insurance purposes. In the case that you are not covered by Aetna, BCBS, Carolina Behavioral Health Alliance, Healthgram, Magellan, MedCost, NC Medicaid, NC HealthChoice, Optum, StarMark, UMR, or United HealthCare you will be responsible to file any claims related to potential reimbursement, and SWTC will not be filing on your behalf.
OUT OF NETWORK:
SWTC encourages clients who have third party health coverage besides that listed above, to file claims themselves and to insist on reasonable coverage for out-of-network benefits (if applicable). In this case, clients may pay the full fee out of pocket, and any reimbursement paid from the insurance company is paid directly to the client. On occasion, SWTC may assist clients with out of network insurance claims, but we are under no obligation to do so. In this case, any moneys paid to SWTC by out of network insurance companies over and above clients’ indebtedness including any interest charges, will be credited or refunded at the end of treatment, or of the fiscal year, whichever comes last.
By signing below, you are acknowledging your understanding that out of network claims will not be filed by SWTC and that there is no implied or expressed guarantee being made, regarding reimbursement by a third party.
I, the undersigned, understand that any third-party reimbursement coverage I may have is a contract between me and my insurance company and that there is no guarantee that SWTC or I will receive any reimbursement. I understand that I am responsible in full for the entire SWTC account balance regardless of what I believe to be my insurance “benefits,” “co-pay,” “coinsurance,” “coverage,” or “my portion,” and regardless of any expectation I have of possible reimbursement by my insurance company or another third party.
I further realize that insurance companies do not reimburse for missed appointments, and that I will be charged the entire out of pocket (non-discounted) session fee if I do not provide at least 24-business hours’ notice to cancel or change appointments. These fees are listed on the “Policies and Procedures” form of Intake Paperwork, which was provided prior to all initial appointments, and is available at any time on the company website or in the office