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Next Generation 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
What brings you to Next Generation PT?
Required
Appointment Location
100 Gateway Drive Cabot AR 72023
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
Friends/ Family
Google
Instagram
Location
Other
Previous Patient
Word of Mouth
Work Comp
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
A G Administrators - A G Administrators Plan
AARP Healthcare Supplement - AARP Healthcare Supplement Plan
AARP UHC Medicare Advantage - AARP UHC Medicare Advantage Plan
ABCBS MEDIPAK PLAN - Bcbs Medipak Plan
Accendo Medicare Supplment - Accendo Medicare Supplement Plan
Accident Fund - Accident Fund Plan
Admiral Life - Admiral Life Plan
Aetna - Aetna Plan
Aetna Medicare - Aetna Medicare Plan
Aetna Medicare Supplement - Aetna Medicare Supplement Plan
AIG - AIG Plan
Align Network - Align Network Plan
All Savers - All Savers Plan
Allstate - Allstate Plan
Allwell - Allwell Plan
Allwell - WELLCARE BY ALLWELL
Ambetter - Ambetter of Arkansas Plan
American Republic - American Republic Plan
AMERICAN SPECIALTY HEALTH - AMERICAN SPECIALTY HEALTH Plan
Amerisure - Amerisure Plan
Amtrust North America - Amtrust North America Plan
AR Kids - AR Kids Plan
AR Kids - ARKANASAS MEDICAID APPEALS
AR Kids - Arkansas School Board Association Plan
Arkansas Bcbs Medipak Advantage - Arkansas Bcbs Medipak Advantage Plan
Arkansas Blue Medicare HMO - Arkansas Blue Medicare HMO Plan
Arkansas Total Care - Arkansas Total Care Plan
Assured Benefits Administrators - Assured Benefits Administrators Plan
ASU Athletics - ASU Athletics Plan
Atlantic Coast Life - Atlantic Coast Life Plan
Bankers Life - Bankers Life Plan
Bardavon Health Innovations - Bardavon Health Innovations Plan
Bcbs Federal - Bcbs Federal Plan
Bcbs Health Advantage - Bcbs Health Advantage Plan
Bcbs Highmark - Bcbs Highmark Plan
Bcbs of Arizona - Bcbs of Arizona Plan
BCBS of Arkansas - Bcbs of Arkanasa Plan
Bcbs of Delaware - Bcbs of Delaware Plan
Bcbs of Louisiana - Bcbs of Louisiana Plan
Bcbs of Michigan - Bcbs of Michigan Plan
Bcbs of South Carolina - Bcbs of South Carolina Plan
Benefit Administrative Systems - Benefit Administrative Systems Plan
Benefit Assistance Corporation - Benefit Assistance Corporation Plan
Bit Co - Bit Co Plan
BMI Benefits - BMI Benefits Plan
Boon Chapman - Boon Chapman Plan
Broadspire - Broadspire Plan
Brotherhood Mutual - Brotherhood Mutual Plan
Care Improvement Plus - Care Improvement Plus Plan
Care Works - Care Works Plan
CCMSI - CCMSI Plan
ChampVA - ChampVA Plan
Cherokee Insurance - Cherokee Insurance Plan
Cigna - Cigna Plan
Cigna - LUCENT HEALTH
Cigna Medicare Supplement - Cigna Medicare Supplement Plan
Community Care VA - Community Care VA Plan
Community Care Optum VA - Community Care Optum VA Plan
Conventry Health Care - Conventry Health Care Plan
Dept of Labor - Dept of Labor Plan
Direct Auto Insurance - DIRECT AUTO INSURANCE PIP DEPARTMENT
Direct Auto Insurance - Direct Auto Insurance Plan
EDIS - Employer Driven Insurance Services Plan
Empower Healthcare Solutions - Empower Healthcare Solutions Plan
Everest Medicare supplement - Everest Medicare supplement Plan
Farm Bureau - Farm Bureau Plan
Farmers - Farmers Plan
Gallagher Bassett - Gallagher Bassett Plan
Geber Medicare Supplement - Geber Medicare Supplement Plan
GEHA - GEHA Plan
Geico Auto Insurance - Geico Auto Insurance Plan
GWH CIGNA - GWH CIGNA Plan
Health Partners - Health Partners Plan
Health Special Risk - Health Special Risk Plan
Healthchoice - Healthchoice Plan
Healthscope - GWH CIGNA
Healthscope - Healthscope Plan
Heartland National Life - Heartland National Life Plan
Highmark BCBS - Anthem Bcbs Plan
Humana - Humana Plan
Ins Management ADM of Louisiana - Ins Management ADM of Louisiana Plan
International Benefits Administrators - International Benefits Administrators Plan
International Benefits Administrators - International Benefits Administrators Plan
K and K - K and K Plan
Kemper Health - Kemper Health Plan
Liberty Mutual - Liberty Mutual Plan
Lucent Health - Lucent Health Plan
Mailhandlers Benefits Fund - Mailhandlers Benefits Fund Plan
Markel - Markel Plan
Medi Share - Medi Share Plan
Medicaid - Medicaid Plan
Medicare - Medicare Example Plan
Medico Insurance Company - Medico Insurance Company Plan
Meritain Health - Meritain Health Plan
Military Assistance Association - Military Assistance Association Plan
MODA Health - MODA Health Plan
Municipal Health Benefit Fund - Municipal Health Benefit Fund Plan
Mutual of Omaha - Mutual of Omaha Plan
Nationwide Mutual - NATIONWIDE CLAIMS ADDRESS
Nationwide Mutual - Nationwide Mutual Plan
NECA IBEW Family - NECA IBEW Family Plan
One Call - One Call Plan
Philadelphia American Life - Philadelphia American Life Plan
Physicians Mutual - Physicians Mutual Plan
Progressive - Progressive Plan
Prosperity Life - Prosperity Life Plan
Public Employee - Public Employee Plan
Qualchoice - Qualchoice Plan
Quality Choice - Quality Choice Plan
Railroad Medicare - Railroad Medicare Plan
Risk Management Resources - RISK MANAGEMENT
Risk Management Resources - Risk Management Resources Plan
RPS Ballinger - RPS Ballinger Plan
Safeco - Safeco Plan
Samba - Samba Plan
Secure Horizons Medicare Supplement - Secure Harizons Medicare Supplement Plan
Sedgwick - Sedgwick Plan
Selman - Selman Plan
Sentinel Security Life - Sentinel Security Life Plan
Southern Guaranty Insurance Company - Southern Guaranty Insurance Company Plan
State Auto Ins - State Auto Ins Plan
State Farm - State Farm Plan
Stonetrust - Stonetrust Plan
Summit Community Care - Summit Community Care Plan
TEAMCARE - TEAM CARE CLAIMS APPEAL
TEAMCARE - USIN Plan
The Hartford - The Hartford Plan
Traveler Auto - Traveler Auto Plan
Travelers - Travelers Plan
Tricare Eastern Region - Tricare Eastern Region Plan
Tricare for Life - Tricare for Life Plan
Tricare Reserve Select - Tricare Reserve Select Plan
Tricare Select - Tricare Select Plan
Tricare West - Tricare West Plan
TRUSTMARK HEALTH BENEFITS - TRUSTMARK HEALTH BENEFITS Plan
UMR - UMR Plan
Unified Life Insurance - Unified Life Insurance Plan
Union Pacfic Railroad - MUNICIPAL WORKERS COMPENSATION
Union Pacfic Railroad - Municipal League Plan
Union Pacfic Railroad - Union Pacfic Railroad Plan
Union Pacfic Railroad Employee Health - Union Pacfic Railroad Employee Health Plan
Union Standard - Union Standard Plan
United American Insurance - United American Insurance Plan
United Healthcare - United Healthcare Plan
UNITED HEALTHCARE GOLDEN RULE - UNITED HEALTHCARE GOLDEN RULE Plan
United Healthcare Medicare Replacement - United Healthcare Medicare Replacement Plan
Unity Health - Unity Health Plan
University of Notre Dame Athletics - University of Notre Dame Athletics Plan
USA Life - USA Life Plan
USAA - USAA Plan
USAA Auto - USAA Auto Plan
WebTPA - WebTPA Plan
Wellcare - Wellcare Plan
Zurich American - Zurich American 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
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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