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Surge Mobile Physical Therapy, PLLC Portal
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New client registration form
E-Mail - This will be your Username
Required
Birthday
Expected format: MM/DD/YYYY
Required
Please Provide a description of why you are wanting Physical Therapy or Stretching Services?
Required
Appointment Location
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 - 3 PM Saturday: 9 AM- 1 PM
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
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
AARP - AARP Plan
Ace Medicare Supplement - Ace Medicare Supplement Plan
ACI - ACI Plan
Aetna - Aetna Example Plan
Aetna Senior Supplement - Aetna Senior Supplement Plan
Allstate Insurance - Allstate Insurance Plan
Amerigroup - Amerigroup Plan
APWU Health Plan - APWU Health Plan Plan
Assured Benefits Administrators - Assured Benefits Administrators Plan
Bankers Life - Bankers Life Plan
BCBS Medicare Advantage - BCBS Medicare Advantage Plan
BCBS texas - BCBS Example Plan
Bind Preferred One - Bind Preferred One Plan
Boon Chapman Administrators Inc - Boon Chapman Administrators Inc Plan
Centivo - Centivo Plan
ChampVa - ChampVa Plan
Charity write off - Charity write off Plan
Cigna ASH - Cigna ASH Plan
Cigna Healthspring - Cigna Healthspring Plan
Consociate - Consociate Plan
Continental Benefits - Continental Benefits Plan
GEHA - GEHA Plan
GPA Imagine 360 - GPA Imagine 360 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
IAC Individual Assurance Company - IAC Individual Assurance Company Plan
Loyal American Life - Loyal American Life Plan
Lumico Medicare Supplement - Lumico Medicare Supplement Plan
Manhattan Life - Manhattan Life Plan
Marpai- S, Texas Health Cooperative medical benefit plan - Marpai Plan
Medica 94265 - Medica 94265 Plan
Medica medm1 - Medica medm1 Plan
Medicaid - Superior Health Plan Medicaid Replacement 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
Pacific Source - Pacific Source Plan
Pekin Life Insurance Medicare Supplement - Pekin Life Insurance Medicare Supplement Plan
Philadelphia American Life Insurance - Philadelphia American Life Insurance Plan
Physicians Mutual Insurance Company - Physicians Mutual Insurance Company Plan
Progressive Auto Insurance - Progressive Auto Insurance Plan
Prominence Administrative Services - Prominence Administrative Services Plan
Providence Health Plan - Providence Health Plan Plan
Providence Risk and Insurance - Providence Risk and Insurance Plan
Railroad Medicare - Railroad Medicare Plan
Realtion Ins Service - Realtion Ins Service Plan
Retirees Welfare Trust - Retirees Welfare Trust Plan
Sage Adjusting LLC a Signal Mutual Company - Sage Adjusting LLC a Signal Mutual Company Plan
Security Health Plan - Security Health Plan Plan
Self pay no form - Self pay no form Plan
State Farm Insurance Company - State Farm Insurance Company Plan
Strategic Comp Claims - Strategic Comp Claims Plan
Student Assurance Services - Student Assurance Services Plan
Supieror Health - Medicaid of Texas Plan
Texas Mutual - Texas Mutual Plan
Texas Work Force - Texas Work Force Plan
The Hartford Work comp - The Hartford Work comp Plan
Thrivent Financial - Thrivent Financial Plan
Transamerica Life Insurance - Transamerica Life Insurance 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 American - United American 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
Western United Life - Western United Life Plan
Zenith Insurance Management Services - Zenith Insurance Management Services 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
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