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Oklahoma Manual Therapy Associates dba CORE Physical Therapy Portal
Install App
Recaptcha v3
New client registration form
E-Mail - This will be your Username
Required
Birthday
Expected format: MM/DD/YYYY
Required
Please describe what we will be seeing you for.
Required
Appointment Location
1410 FRETZ DR EDMOND OK 73003
Required
When are you available to come in?
Required
Referring Provider
First Name
Required
Middle Name
Last Name
Required
Gender
Female
Male
Required
How did you hear about us?
Client Referral
Doctor
Email
Facebook
Google
Location
MVA
Other
Print Promo
Radio
Re-activation
Work Comp
Workshop
Yelp
Required
Home Address
Required
Apt, Ste, or Floor (Optional)
City
Required
State
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Required
Zip Code
Required
Phone Number
Required
Phone Type
Cell
Home
Work
Required
Insurance - If applicable
Self Pay / No Insurance
90 Degree Benefits - OK - 90 Degree Benefits OK Plan
AAA - AAA Plan
AAA - AAA Plan
AARP Medicare Advantage HMO UHC - AARP Medicare Advantage HMO POS UHC Plan
AARP Medicare Supplement - AARP Medicare Supplement Plan
ACE Medicare Supplement - ACE Property and Casuality Plan
Aetna - Aetna Example Plan
Aetna Continental Life Ins - Aetna Continental Life Ins Plan
Aetna Medicare - Aetna Medicare Plan
Aetna Senior Supplemental - Aetna Senior Supplemental Plan
Allied Benefits Systems - Allied Benefits Systems Plan
AM Trust North America - AM Trust North America Plan
Atlantic Coast Life - Atlantic Coast Life Plan
Atlantic Coast Life - United Healthcare Choice Plus Plan
Auxiant - Auxiant Plan
Bankers Fidelity - Bankers Fidelity Plan
Bankers Life and Casualty - Bankers Life and Casualty Plan
BCBS - Federal - BCBS Federal Plan
BCBS Medicare Advantage - BCBS Medicare Advantage Plan
BCBS of OK - BCBS of Oklahoma
BMI Benefits LLC Claims - BMI Benefits LLC Claims Plan
CHAMPVA - CHAMPVA Plan
Cigna - Cigna Plan
Cigna ASH - Cigna ASH Plan
Cigna Medicare Supplement - Cigna Medicare Supplement Plan
Colonial Penn Life Ins Co - Colonial Penn Life Ins Co Plan
Community Care HMO - Community Care HMO Plan
Connect Benefit - Connect Benefit Plan
Consolidated Benefits Resources - Consolidated Benefits Resources Plan
Continental General Ins Co - Continental General Ins Co Plan
Crum and Forster Medicare Supplement - Crum and Forster Medicare Supplement Plan
EBMS - EBMS Plan
EMC Insurance Companies - EMC Insurance Companies Plan
EMI Health - EMI Health Plan
Equity Insurance - Equity Insurance Plan
GEHA - GEHA Plan
Geico Casualty - Geico Casualty Plan
Great Southern Life Insurance Co - Great Southern Life Insurance Co Plan
Healthcare Highways - Healthcare Highways Plan
HealthCare Solutions Group - HealthCare Solutions Group Plan
HealthChoice - HealthChoice Plan
HealthPartners - HealthPartners Plan
HealthSmart - HealthSmart Plan
HP Enterprises - HP Enterprises Plan
Humana - Humana Plan
Humana Health Horizons - Medicaid - Humana Healthy Horizons Medicaid Plan
Kempton Group Admin - Kempton Group Admin Plan
Liberty Mutual - Liberty Mutual Plan
MEDICAID - MEDICAID Plan
Medicare - Medicare Plan
Meritain Health - Meritain Plan
MHBP - MHBP Plan
Mutual of Omaha - Mutual of Omaha Plan
New Era Life Ins - New Era Life Ins Plan
Oklahoma Farm Bureau - Oklahoma Farm Bu Plan
Old Surety LIfe - Old Surety LIfe Plan
One Call Physical Therapy - One Call Physical Therapy Plan
OSMA - OSMA Plan
PHCS - Freedom Life Ins Co Plan
Philadelphia American Life - Philadelphia American Life Plan
Physicians Mutual - Physicians Mutual Plan
Potawatomi - Citizen of Potawatomi Nation Plan
Railroad Medicare - Railroad Medicare Plan
Rising Medical Solutions - Rising Medical Solutions Plan
Rogers Blue Jays Baseball Partnership - Rogers Blue Jays Baseball Partnership Plan
Sedgwick - Sedgwick Plan
SILAC - SILAC Plan
STATE FARM - STATE FARMS Plan
State Farm - State Farm Plan
Surest - Surest Plan
Taro Health - Taro Health Plan
The Harford - The Harford Plan
Travelers Property Casualty - Travelers Property Casualty Plan
Tricare East - Tricare Example Plan
Tricare for Life - Tricare for Life Example Plan
TriWest - TriWest Plan
UMR - UMR Plan
UMR Wausau - UMR Wausau Plan
United Healthcare All Savers - United Healthcare All Savers Plan
United Healthcare Medicare Advantage - United Healthcare Medicare Advantage Plan
United Healthcare Shared Services - United Healthcare Shared Services Plan
UnitedHealthOne Plan - UnitedHealthOne Plan
Universal Fidelity - Universal Fidelity Plan
USAA Life Ins Co - USAA Life Ins Co Plan
Vox Printing - Vox Printing Plan
WebTPA - WebTPA Plan
Member ID
Required
Group Number
Are you the policy holder?
Yes
No
Required
I have a secondary insurance policy and will provide details upon arrival
Other Insured
Please provide the policy holders information. For example, if this is your spouses policy you would enter their information in the corresponding fields below.
Policy holder First Name
Required
Policy holder Middle Name
Policy holder Last Name
Required
Relationship to insured
Child
Other
Spouse
Employee
Unknown
Life Partner
Mother
Required
Policy holder Gender
Female
Male
Required
Policy holder Birthday
Expected format: MM/DD/YYYY
Required
Policy holder Address
Required
Policy holder Suite, PO Box, etc.
Policy holder City
Required
Policy holder State
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Required
Policy holder Zip Code
Required
Password
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