Initial Consultation Form

Are you interested in what Nardone Chiropractic can do for you? Fill out the form below to contact Nardone Chiropractic and schedule an initial consultation.

Note: All fields marked with a * are required fields.

Full Name*


E-mail Address*


Phone Number*


Best Time to Call


Would you prefer to be contacted by phone or E-mail?
Phone Email

New Patient Forms

Below you will find the Nardone Chiropractic New Patient Forms in PDF Format. Click the PDF icons to download and print the forms to take to your first visit.

CONFIDENTIAL PATIENT CASE HISTORY
PHONE CONSENT FORM — Let Nardone know who it may leave information, such as test results, with in your household.
PAIN SCALE — In Pain? Let us know the severity using the scales on this form.

Personal Injury Forms

Have you been personally injured in an accident? Would you like to find out how Nardone Chiropractic can help relieve your pain and get you back to a normal life? Click the PDF icons to download and print our Personal Injury and Toxicity Questionaire forms.

PERSONAL INJURY FORM

Financial Policy

METHODS OF PAYMENT

• Cash
• Check
• Major Credit Cards
• Extended Payment Plans (Healthcare Payment Solutions)

Our policy is to extend to you the courtesy of allowing you to assign your insurance benefits directly to us. This policy reduces your out-of-pocket expense and allows you to place your family under care.

1. If You Do Not Have Insurance: All payments are expected at the time of service or by an authorized payment plan. Your personal balance may not exceed $100 at any time or care may be terminated. Our payment plans make care an affordable part of your family budget.

2. If You Have Insurance: All deductibles and co-payments are expected at the time of service or by an authorized payment plan. Your co-insurance balance may not exceed $100 or care may be terminated. Our payment plans make care an affordable part of your familybudget.

You are considered a cash patient until you bring in your completed insurance forms, and we qualify and accept your insurance coverage. We do not accept assignment for secondary insurance carriers, but will be happy to provide you with a claim form for yoursecondary carrier.

Our fees are considered usual, customary and reasonable by most companies, and therefore are covered up to the maximum allowance determined by each carrier. This statement does not apply to companies who reimburse based on an arbitrary schedule of fees bearing no relationship to the current standard and of care in this area.

If your carrier has not paid a claim within sixty (60) days of submission, you agree to take an active part in the recovery of your claim. If your insurance carrier has not paid within ninety (90) days of submission, you accept responsibility for payment in full of any outstandingbalance and authorize us to use your credit card to collect full payment.

When your schedule of visits is once per month or longer, you will not be eligible for insurance assignment. Charges for services rendered will be due as they are rendered. We will continue to provide you with an insurance claim form.

If you discontinue care for any reason other than discharge by the doctor, all balances will become immediately due and payable in full by you, regardless of any claim submitted.

Insurers List

Nardone Chiropractic & Wellness participates with many health insurers, we even take care of filing all of your claims for you! We accept all insurances and are credentialed with the following:

• Anthem BCBS
• Mountain State BCBS
• Highmark BCBS
• Federal BCBS
• Aetna
• ACN Group
• CareLink
• Cigna PPO
• First Health
• Great West
• GE Wellness Plan
• Golden Rule
• 4-Most
• Health Allies
• Health America/Health Assurance
• WV Medicaid (Traditional)
• PEIA/Wells Fargo TPA
• WV, PA & OH Worker's Comp.
• Mamsi
• Medical Resources, PLLC
• Private Healthcare Systems
• United Healthcare
• Select Net Plus
• Variable Protection
• Health Plan