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Lifestyle Physical Therapy LLC 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 are you seeking physical therapy for?
Required
Appointment Location
1023 N Royal St. Unit 101 ALEXANDRIA VA 22314
4543 Charlotte Hwy Clover SC 29710
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?
Commercial
Doctor
Facebook
Friend
Google
I am a returning client
Other
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
AARP - AARP Plan
AARP Complete United Healthcare - AARP Complete United Healthcare Plan
AARP Health Care Options - AARP Health Care Options Plan
AARP Medicare Supplement - AARP Medicare Supplement Plan
ACE Chubb - ACE Chubb Plan
Aetna - Aetna Plan
Aetna Life Insurance Co. non medicare - Aetna Life Insurance Co. non medicare Plan
Aetna Life Insurance Company - Aetna Life Insurance Company Plan
Aetna Medicare - Aetna Medicare Plan
Aetna Medicare Advantage PPO - Aetna Medicare Advantage PPO Plan
Aetna Senior Supplemental - Aetna Senior Supplemental Plan
Aetna US Healthcare - Aetna US Healthcare Plan
Aetna Virginia - Aetna Plan
Allstate - Allstate Plan
Allstate - Allstate Plan
American Continental Insurance Company - American Continental Insurance Company Plan
American Group Administrators - American Group Administrators Plan
American Healthcare Alliance - American Healthcare Alliance Plan
American Retirement - American Retirement Plan
Americas 1st Choice - Americas 1st Choice Plan
Americas Choice Provider Network - Americas Choice Provider Network Plan
Americo Financial Life/ Great Southern Life Ins - Americo Financial Life/ Great Southern Life Ins Plan
Association and SOCI - Association and SOCI Plan
Assurant Health - Assurant Health Plan
AVMA - AVMA Plan
AvMed - AvMed Plan
Bankers Fidelity - Bankers Fidelity Plan
Bankers Life and Casualty Company - Bankers Life and Casualty Company Plan
Bardavon Health Innovations - Bardavon Health Innovations Plan
BCBS SC - BCBS SC Plan
BCBS SC - Blue Choice
BCBS SC - Blue Essential
BCBS SC - Blue Options
BCBS SC - Preferred Blue
BCBS SC - SC BCBS State Employee Health Plan
BCBS Virginia Federal employee - Bluecross Blueshield Virginia Plan
Blue Cross Blue Shield Medicare - Blue Cross Blue Shield Medicare Plan
Bluecross Blueshield - Bluecross Blueshield Plan
Bluecross Medicare Advantage - Bluecross Medicare Advantage Plan
Bob McCloskey Insurance Benefits, LLC - Bob McCloskey Insurance Benefits, LLC Plan
Bollinger Inc. - Bollinger Inc. Plan
Bollinger, Inc - Bollinger, Inc Plan
Brentwood Services - Brentwood Services Plan
Care Improvement Plus - Care Improvement Plus Plan
Care Improvement Plus Medicare Advantage PPO - Care Improvement Plus Medicare Advantage PPO Plan
CareIQ - CareIQ Plan
Carolinas HealthCare System ATTN: Work Comp - Carolinas HealthCare System ATTN: Work Comp Plan
Central States Indemnity (CSI) - Central States Indemnity (CSI) Plan
CHAMPVA - CHAMPVA Plan
Chartis - Chartis Plan
Chesterfield Resources Inc. - Chesterfield Resources Inc Plan
CHUBB - CHUBB Plan
Cigna - Cigna Appeals Unit
Cigna - Cigna Plan
Cigna Medicare Not INN - Cigna Medicare Not INN Plan
Cigna PPO / Indemnity - Cigna PPO / Indemnity Plan
Co-ordinated Benefit Plans, LLC - Co-ordinated Benefit Plans, LLC Plan
Colonial Penn Life - Colonial Penn Life Plan
Combined Insurance Company of America - Combined Insurance Company of America Plan
Cooperative Benefit Administrators, Inc - Cooperative Benefit Administrators, Inc Plan
Coresource - Coresource Plan
Corporate Benefits Services - Corporate Benefits Services Plan
Coventry Health Care of the Carolinas, Inc - Coventry Health Care of the Carolinas, Inc Plan
Crum and Forster - Crum and Foster Plan
Department of Veterans Affairs - Department of Veterans Affairs Plan
Disability Determination Services - Disability Determination Services Plan
EBS-RMSCO, Inc. - EBS-RMSCO, Inc. Plan
Encompass Insurance - Encompass Insurance Plan
Equitable Life and Casualty Insurance Company - Equitable Life and Casualty Insurance Company Plan
Evolution - Evolution Plan
Family Life Insurance Company - Family Life Insurance Company Plan
Forethought Life Insurance Company - Forethought Life Insurance Company Plan
GAB Robbins - GAB Robbins Plan
Gallagher Bassett - Gallagher Bassett Plan
GEHA - GEHA Plan
Gerber - Gerber Plan
GHI (EmblemHealth PPO/EPO) - GHI (EmblemHealth PPO/EPO) Plan
GPM Life - GPM Life Plan
Great American Life Insurance Co - Great American Life Insurance Co Plan
Great West - Great West Plan
Great West-Cigna - Great West-Cigna Plan
Hartford Insurance - Hartford Insurance Plan
health equity, inc - health equity, inc Plan
Health Options Program - Health Options Program Plan
Health Plans Inc - Health Plans Inc Plan
Health Special Risk, Inc - Health Special Risk, Inc Plan
Healthnet Federal Services - Healthnet Federal Services Plan
Heartland National Life Insurance - Heartland National Life Insurance Plan
Horizon Blue Cross Blue Shield of New Jersey - Horizon Blue Cross Blue Shield of New Jersey Plan
Humana Choice - Humana Choice Plan
Humana Gold - Humana Gold Plan
Humana Gold Choice - Humana Gold Choice Plan
Humana Military Tricare East - Humana Military Tricare East Plan
Humana PPO - Humana PPO Plan
IAC - IAC Plan
Individual Assurance Company - Individual Assurance Company Plan
Kaiser Permanente - Kaiser Permanente Plan
Lifetime Benefit Soultions - Lifetime Benefit Soultions Plan
Limited Partners - Strategic Limited Partners Plan
Loyal American - Loyal American Plan
Lumico - Lumico Plan
Maksin Management Corp. - Maksin Management Corp. Plan
Manhattan Life Insurance Co - Manhattan Life Insurance Co Plan
Medcost - Medcost Plan
Medicaid Claims Receipt - Medicaid Claims Receipt Plan
Medicare South Carolina - Medicare South Carolina Plan
Medico Corp Life Insurance Company - Medico Corp Life Insurance Company Plan
Medrisk - Medrisk Plan
MedRisk EPO - MedRisk EPO Plan
Meritain Health - Meritain Health Plan
MHBP - MHBP Plan
Military Officers Association of America - Military Officers Association of America Plan
Molina Healtchare of South Carolina - Molina Healtchare of South Carolina Plan
Mutual Of Omaha - Mutual Of Omaha Plan
MVP Medicare Advantage Plan - MVP Medicare Advantage Plan Plan
NALC - NALC Health Benefit Plan Plan
Nationwide - Nationwide Plan
Nationwide Insurance - Nationwide Insurance Plan
New Era Life Insurance Companies - New Era Life Insurance Companies Plan
No Insurance Selected - No Insurance Selected Plan
Northwestern Administrators, Inc. - Northwestern Administrators, Inc. Plan
NYS Empire Plan UHC - NYS Empire Plan UHC Plan
Oldsmar Service Center - Oldsmar Service Center Plan
Oxford Life Insurance - Oxford Life Insurance Plan
Physicians Mutual - Physicians Mutual Plan
Primary Care Physicians - Primary Care Physicians Plan
Prosperity Life Group - Prosperity Life Group Plan
Pyramid Life - Pyramid Life Plan
Quantum Health - Quantum Health Plan
Risk Enterprise Management - Risk Enterprise Management Plan
Royal Neighbors of America - Royal Neighbors of America Plan
RPN - RPN Plan
SC Workmans Comp - SC Workmans Comp Plan
SCSBIT - SCSBIT Plan
Secure Horizons - Secure Horizons Plan
Sedgwick - Sedgwick Plan
Select Health of South Carolina - Select Health of South Carolina Plan
SPNet Workman's Comp American Airlines - SPNet Workmans Comp American Airlines Plan
Standard LIfe and Accident Insurance Co - Standard LIfe and Accident Insurance Co Plan
Starmark - Starmark Plan
State Farm Health Insurance - State Farm Health Insurance Plan
State Farm Insurance - State Farm Insurance Plan
Strategic Comp - Strategic Comp Plan
SuperMed PPO Access - SuperMed PPO Access Plan
Thrivent Financial for Lutherans - Thrivent Financial for Lutherans Plan
TransAmerica Life Insurance Company - TransAmerica Life Insurance Company Plan
Tricare - Tricare Plan
Tricare/ChampVA Supplement Plan - Selman ChampVA Plan
Trustmark Health Benefits - Trustmark Health Benefits Plan
UMR - UMR Plan
UMWA - UMWA Plan
United American Insurance Company - United American Insurance Company Plan
United Healthcare - United Healthcare Plan
United Healthcare Insurance Company - United Healthcare Insurance Company Plan
United Healthcare Medicare advantage - United Healthcare Medicare advantage Plan
United Healthcare Medicare Advantage PPO - United Healthcare Medicare Advantage PPO Plan
United Healthcare Medicare Solutions - United Healthcare Medicare Solutions Plan
United HealthCare Options PPO - United HealthCare Options PPO Plan
United Teachers - United Teachers Plan
United World Life Insurance Company - United World Life Insurance Company Plan
Universal Health Care Insurance Company, Inc - Universal Health Care Insurance Company, Inc Plan
US Health Group (Virginia) - US Health Group Plan
USAA - USAA Plan
VA Community Care Network - VA Community Care Network Plan
VACAA - VACAA Plan
Veterans Administration - Veterans Administration Plan
Veterans Administration Optum CCN - Veterans Administration Optum CCN Plan
Veterans Administration Out of Network CCN - Veterans Administration Out of Network CCN Plan
Webtpa - Webtpa Plan
Webtpa Secondary to Tricare - Webtpa Secondary to Tricare Plan
Wellabe Medicare Supplement - Wellabe Plan
WellCare Medicare Advantage / WellCare Health Plan Inc - WellCare Medicare Advantage Plan
Wex Health - WEX Health inc Plan
Workman's Comp / Travelers Insurance - SPNet Workmans Comp Plan
Zuffa LLC - Zuffa LLC Plan
Zurich - Zurich 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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