Skip to Main Content
Ford Physical Therapy, PLLC Portal
Recaptcha v3
New client registration form
E-Mail - This will be your Username
(Value Required)
Required
Birthday
(Value Required)
Expected format: MM/DD/YYYY
Required
What kind of issues are you experiencing?
(Value Required)
Required
Appointment Location
(Value Required)
3418 West Main Street Suite B Tupelo MS 38801 | 8-5:30
Required
Referring Provider
First Name
(Value Required)
Required
Middle Name
Last Name
(Value Required)
Required
Gender
(Value Required)
Female
Male
Required
How did you hear about us?
(Value Required)
Client Referral
Doctor
Email
Facebook
Google
Location
Other
Trainer
Work Comp
Yelp
Required
Home Address
(Value Required)
Required
Apt, Ste, or Floor (Optional)
City
(Value Required)
Required
State
(Value Required)
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
(Value Required)
Required
Phone Number
(Value Required)
Required
Phone Type
(Value Required)
Cell
Home
Work
Required
Insurance - If applicable
Self Pay / No Insurance
Aetna - Aetna
Aetna and Aetna Medicare - Aetna Example Plan
American Continental Insurance Aetna - American Continental Insurance Aetna Plan
Bankers Fidelity - Bankers Fidelity Plan
BCBS - Blue Cross Blue Shield
BCBS AHS - Blue Cross Blue Shield AHS Plan
BMI Benefits School - BMI Benefits School Plan
Bollinger Inc. - Bollinger Inc Plan
Champ VA - Champ VA Plan
Cigna - Cigna Plan
Cigna Great West Healthcare - Cigna Great West Healthcare Plan
Eastern Alliance Insurance Group - Eastern Alliance Insurance Group Plan
ESIS Central WC Claims - ESIS Central WC Claims Plan
Everest - Everest Plan
Fidelity Security Life Forrest T Jones and Company - Forrest T Jones and Company Plan
Fox Everett - Fox Everett Plan
Heath Scope - Heath Scope Plan
Humana - Humana Plan
Humana Medicare - Railroad Medicare Plan
Humana Tricare East - Champus Tricare North South Plan
Jopari Liberty Mutual - Jopari Solutions Plan
Liberty Mutual Insurance - Liberty Mutual Insurance Plan
Lucent Health - Lucent Health Plan
Lumico - Lumico Plan
Manhattan Life Insurance - Manhattan Life Insurance Plan
Mayfield Law - Mayfield Law Plan
Medadvo - Wheeler and Franks Law Firm Medadvo Plan
Medicare - Medicare Plan
MedPlus Gulf Guaranty Health - MedPlus Plan
Medrisk - Medrisk Plan
Mitsui Sumitomo - Mitsui Sumitomo Plan
MS Medicaid - MS Medicaid Plan
Mutual of Omaha - Mutual of Omaha Plan
Pan American Life - Pan American Life Plan
Pekin Insurance - Pekin Insurance Plan
Philadelphia American Life Insurance - Philadelphia American Life Insurance Plan
Progressive Insurance - Progressive Insurance Plan
Railroad Medicare - Railroad Medicare Plan
Southern Guaranty Insurance Company Medicare - Southern Guaranty Insurance Company Plan
State Auto - State Automobile Mutual Ins Comp Plan
State Farm Medicare Insurance - State Farm Medicare Insurance Plan
Strategic Comp - Strategic Comp Plan
Travelers Ins - Travelers Ins Plan
Tricare for Life - Tricare for Life Example Plan
TriWest - TriWest Plan
UHC - United HealthCare Plan
UMR - UMR
United American Insurance Company - United American Insurance Company Plan
Member ID
(Value Required)
Required
Group Number
Are you the policy holder?
(Value Required)
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
(Value Required)
Required
Policy holder Middle Name
Policy holder Last Name
(Value Required)
Required
Relationship to insured
(Value Required)
Child
Other
Spouse
Employee
Unknown
Life Partner
Mother
Required
Policy holder Gender
(Value Required)
Female
Male
Required
Policy holder Birthday
(Value Required)
Expected format: MM/DD/YYYY
Required
Policy holder Address
(Value Required)
Required
Policy holder Suite, PO Box, etc.
Policy holder City
(Value Required)
Required
Policy holder State
(Value Required)
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
(Value Required)
Required
Password
Password
(Value Required)
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
(Value Required)
Required
Cancel
Existing Users Login Here
Continue