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

INSURANCE, 3RD PARTY REIMBURSEMENT INFORMATION AND RELEASE FORM

PLEASE COMPLETE ONE PER INSURED PERSON IF PLANNING TO FILE IN- OR OUT-OF-NETWORK CLAIMS
 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
 
 

COUPLES/FAMILY/CHILD/GROUP THERAPY POLICY

 COUPLES/FAMILY/CHILD/GROUP THERAPY IS DIFFERENT:
This statement of policy is intended to inform all participants in couples, family, child, or group therapy how therapists at Shelby Wellness and Therapy Center choose to handle privacy/confidentiality, as well as the treatment records, which is fundamentally different than in the case of individual therapy. 
 
TREATMENT UNIT: 
When SWTC therapists agree to treat a couple, family, child, or group, we consider everyone attending (also known as the “treatment unit”) to be the client. If, for example, clinical records of the treatment unit were ever requested by anyone, inside or outside the treatment unit, your therapist would be required to seek the authorization of all members of the treatment unit before releasing any confidential information, and would not release any information without this authorization (see exceptions to this on SWTC’s “Informed Consent” document which all new clients receive at the onset of therapy). If clinical records were ever subpoenaed in a legal situation, your therapist would assert the psychotherapist-client privilege on behalf of the entire treatment unit. 
 
 CONFIDENTIALITY IN COUPLES/FAMILY/CHILD/GROUP THERAPY:
During the course of couples, family, child, or group therapy, your therapist may find it clinically appropriate to consult with a smaller set of the larger treatment unit (e.g. an individual or two siblings) for one or more sessions. Unless occurring for specific, individual issues that are unrelated to the couples/family/child/group work, these sessions would be seen by all participants of the treatment unit as a part of the larger whole: the work that the entire treatment unit is doing, unless otherwise indicated. If you are involved in one or more of such sessions with your therapist, please understand that generally these sessions are still considered confidential in the sense that your therapist would not release any confidential information to a third party unless required to do so by law, or prior written authorization was provided. In fact, since those sessions can and should be considered a part of the treatment of the couple or family, we would also seek the authorization of the other individuals in the treatment unit before releasing confidential information to a third party. 
 
 “NO SECRETS”:
 However, your therapist may find it clinically necessary to discuss information learned in a session with only a portion of the treatment unit being present, with the entire treatment unit – that is, the family, couple, or group – to effectively serve the goals of the unit being treated. Your therapist will use professional judgment as to whether, when, and what extent they may make disclosures to the treatment unit, and will also, if appropriate, first inform and give the individual or the smaller part of the treatment unit being seen the opportunity to make the disclosure. Thus, if any individual within the treatment plan feels it necessary to talk about matters that they absolutely do not want shared with anyone else in the larger treatment unit, a consultation with an individual therapist who can help treat you individually may be necessary. SWTC can make a referral to an individual therapist in this case.

This “no secrets” policy is intended to allow your therapist to continue to treat the couple, family, child, or group, by preventing, to the greatest extent possible, a conflict of interest to arise where an individual’s interests may not be consistent with the interests of the treatment unit. For instance, information learned in the course of an individual session may be relevant or even essential to the proper treatment of the couple of the family. If your therapist is not free to exercise clinical judgment regarding the need to bring this information to the couple, family, or group during their therapy, your therapist might be placed in a situation where termination of treatment is necessary. This policy is intended to prevent the need for such a termination.

If choosing to engage in couples, family, child, or group therapy, please sign at the bottom of this document. A signature on this agreement indicates that each member of the treatment plan has read or had read to them, this policy, has had an opportunity to discuss its contents with the therapist, and chooses to undertake couple/family/group therapy in agreement with and with an understanding of how this policy may impact confidentiality and the handling of any records.
 

 
 

Signature of Client/legal Guardian: