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Surge Mobile Physical Therapy, PLLC Portal
Recaptcha v3
New client registration form
E-Mail - This will be your Username
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Birthday
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Expected format: MM/DD/YYYY
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Please Provide a description of why you are wanting Physical Therapy or Stretching Services?
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Appointment Location
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413 E. Railroad Ave. Suite A Port Isabel TX 78578 | Monday- Friday: 8 AM - 5 PM
7135 FRONTAGE RD OLMITO TX 78575 | Monday- Thursday: 8 AM - 7 PM Friday: 8 AM - 1 PM Saturday: 9 AM- 1 PM
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Referring Provider
First Name
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Middle Name
Last Name
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Gender
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Female
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How did you hear about us?
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Client Referral
Doctor
Email
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Other
Print Promo
Workshop
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Home Address
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Apt, Ste, or Floor (Optional)
City
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State
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Zip Code
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Phone Number
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Phone Type
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Cell
Home
Work
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Insurance - If applicable
Self Pay / No Insurance
AARP - AARP Plan
Aetna - Aetna Example Plan
Aetna Senior Supplement - Aetna Senior Supplement Plan
Allstate Insurance - Allstate Insurance Plan
Amerigroup - Amerigroup Plan
Assured Benefits Administrators - Assured Benefits Administrators Plan
Bankers Life - Bankers Life Plan
BCBS texas - BCBS Example Plan
Bind Preferred One - Bind Preferred One Plan
Blue Cross Advantage Medicare - Blue Cross Advantage Medicare Plan
Boon Chapman Administrators Inc - Boon Chapman Administrators Inc Plan
Centivo - Centivo Plan
ChampVa - ChampVa Plan
Cigna ASH - Cigna ASH Plan
Cigna Healthspring - Cigna Healthspring Plan
Continental Benefits - Continental Benefits Plan
GEHA - GEHA Plan
Group and Pension Administrators - Group and Pension Administrators Plan
Health Partners Claims - Health Partners Claims Plan
Heil Law Firm - Heil Law Firm Plan
Holista - Holista Plan
Humana - Humana Plan
Loyal American Life - Loyal American Life Plan
Manhattan Life - Manhattan Life Plan
Marpai- S, Texas Health Cooperative medical benefit plan - Marpai Plan
Medicaid of Texas - Medicaid of Texas Plan
Medico - Medico Plan
Mid Central Operating Engineers Health and Welfare Fund - Mid Central Operating Engineers Health and Welfare Fund Plan
Molina - Molina Plan
Mountain Valley - WellMed Medical Claims Plan
Omaha Supplement - Omaha Supplement Plan
Philadelphia American Life Insurance - Philadelphia American Life Insurance Plan
Physicians Mutual Insurance Company - Physicians Mutual Insurance Company Plan
Providence Risk and Insurance - Providence Risk and Insurance Plan
Railroad Medicare - Railroad Medicare Plan
Realtion Ins Service - Realtion Ins Service Plan
State Farm Insurance Company - State Farm Insurance Company Plan
Student Assurance Services - Student Assurance Services Plan
Superior Health Plan Medicaid Replacement - Superior Health Plan Medicaid Replacement Plan
Texas Mutual - Texas Mutual Plan
Texas Work Force - Texas Work Force Plan
Thrivent Financial - Thrivent Financial Plan
Tricare East - Tricare Example Plan
Tricare for Life - Tricare for Life Example Plan
Trustmark Benefits - Trustmark Benefits Plan
UMR Formerly UMR Wausau - UMR Formerly UMR Wausau Plan
United Health Care Community Care - United Health Care Community Care Plan
United HealthCare - United HealthCare Plan
United Healthcare All Savers Alternate Funding - United Healthcare All Savers Alternate Funding Plan
USAA - USAA Plan
Veteran Family Member - Veteran Family Member Plan
Web TPA Community Health Electronic Claims Chec - Web TPA Community Health Electronic Claims Chec Plan
Member ID
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Group Number
Are you the policy holder?
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Yes
No
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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
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Policy holder Middle Name
Policy holder Last Name
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Relationship to insured
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Child
Other
Spouse
Employee
Unknown
Life Partner
Mother
Required
Policy holder Gender
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Female
Male
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Policy holder Birthday
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Expected format: MM/DD/YYYY
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Policy holder Address
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Policy holder Suite, PO Box, etc.
Policy holder City
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Policy holder State
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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
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Policy holder Zip Code
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Password
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