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Physical Therapy 180, LLC Portal
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New client registration form
E-Mail - This will be your Username
Required
Birthday
Expected format: MM/DD/YYYY
Required
What is the reason for your appointment today?
Required
Appointment Location
5909 W. State St. Boise ID 83703 | M - Th 7am - 6pm F 7am - 5pm
Required
Referring Provider
First Name
Required
Middle Name
Last Name
Required
Gender
Female
Male
Required
How did you hear about us?
Doctor
Employee
Facebook
Google
In-network Insurance
Location
Other
Patient Referral
Previous Patient
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
AARP HEALTHCARE OPTION CLAIMS DIVISION - AARP HEALTHCARE OPTION CLAIMS DIVISION Plan
AETNA - AETNA Brentwood
ALLSTATE HEALTH SOLUTIONS SUPPLEMENTAL INS - ALLSTATE HEALTH SOLUTIONS Plan
Associated Loggers Exchange - Associated Loggers Exchange Plan
AUTO OWNERS - AUTO OWNERS Plan
Banafsheh Danesh and Javid PC - BD and J PC Plan
BLUE CROSS - BLUE CROSS Plan
CHAMPVA - CHAMPVA Plan
CIGNA - CIGNA Chattanooga 182223
FIRST CHOICE HEALTH - FIRST CHOICE HEALTH Plan
GEHA - GEHA FEHB Eagan
HUMANA MEDICARE ADVANTAGE - HUMANA Commercial
IAC - IAC Plan
iii A - iii A Plan
INTERCARE - INTERCARE Plan
LIBERTY MUTUAL INSURANCE - LIBERTY MUTUAL INSURANCE WC
MEDICAID - MEDICAID Plan
MEDICARE - MEDICARE Plan
Molina Healthcare Medicaid Plus - MOLINA HEALTHCARE OF IDAHO Plan
MOLINA HEALTHCARE OF IDAHO - MOLINA MEDICAID Plan
MOUNTAIN HEALTH CO OP. UNIVERSAL FIDELITY LIFE - MOUNTAIN HEALTH CO OP Plan
OPTUM - OPTUM Plan
PACIFIC SOURCE - PACIFIC SOURCE Plan
PROVIDENCE - PROVIDENCE Plan
REGENCE BLUE SHIELD - REGENCE BLUE SHIELD Plan
Risk Management - San Bernardino Co Plan
SELECT HEALTH - SELECT HEALTH 30196
SELECT HEALTH - SELECT HEALTH Plan
Self Pay - Self Pay Plan
Southern California Soft Drink Industry and Teamsters Health and Welfare Trust Fund - Southern California Soft Drink Industry and Teamsters Health and Welfare Trust Fund Plan
ST LUKES HEALTH PLAN - ST LUKES HEALTH PLAN Plan
STATE FARM AUTO - STATE FARM PNW Plan
State Farm Claims - State Farm Claims Plan
TRAVELERS - TRAVELERS Plan
Tri Star - Tri Star Plan
TRICARE - TRICARE ACTIVE DUTY Florence
U A Local 290 Health Trust - U A Local 290 Health Trust Plan
UMR - UMR Plan
UNITED HEALTH CARE - UHC MEDICARE ADVANTAGE Salt Lake City
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
Password
Required
1. Length 12-30
2. One or More Upper AND Lowercase Characters
3. One or More Numeric
4. One or More of the following: !@#$%^&*()~:";<>?,./
Confirm Password
Required
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