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Adjuvant Physical Therapy LLC Portal
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Recaptcha v3
New client registration form
E-Mail - This will be your Username
Required
Birthday
Expected format: MM/DD/YYYY
Required
Please provide a brief description of your reason for referral.
Required
Appointment Location
20101 East Jackson Drive Independence MO 64014
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
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
A G Administrators LLC - A G Administrators LLC Plan
AARP Mcr Adv - AARP Medicare Advantage Plan
BCBS of Michigan - BCBS of Michigan Plan
CHAMPVA - CHAMPVA Plan
Cottingham and Butler - Cottingham and Butler Plan
First Health - First Health Plan
Freedom Medical Network Med Pay - Freedom Medical Network Med Pay Plan
GAIG - HealthOne Plan
GEHA - GEHA Plan
Home State Medical - Home State Medical Plan
Individual Assurance Company - Individual Assurance Company Plan
Iron Road Healthcare - Iron Road Healthcare Plan
Line Construction Benefit Fund - Line Construction Benefit Fund Plan
Manhattan Life Insurance - Manhattan Life Insurance Plan
Medicaid MO - Medicaid MO Plan
Medicare - Medicare Plan
Medicare Supplement - AARP Plan
Medicare Supplement: Transamerica - Transamerica Life Insurance Plan
Medico - Medico Plan
Mutual of Omaha - Mutual of Omaha Plan
National General Accident and Health - National General Accident and Health Plan
Nationwide Mutual Insurance - Nationwide Mutual Insurance Plan
RAS Workers Compensation - RAS Workers Compensation Plan
RR Medicare - Railroad Medicare Plan
Self Pay - Self Pay with Super Bill Plan
Shelter Insurance - Shelter Insurance Plan
Sisco - Sisco Plan
State Farm - State Farm Plan
UMR - UMR 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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