New Clinic Form

Use this form to add your Physical Therapy Clinic to our team of partners.

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Clinic/Facility Name:

Name of a Billing Contact in your clinic:

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Phone Number:

Email address for administrative contact:

Street Address:

City:

State: AK AL AZ BC CA CO CT DC DE FL GA HI IA ID IL KS KY LA MA MD ME MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OK OR PA RI SC SD TN TX UT VA VT WA WI WV WY

Zip Code:

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Does your clinic provide a computer and Web access for Staff:

Yes	No

Does your clinic provide computer and Web access for Patients:

Yes	No

Number of Therapists on staff:

Comments:

Please this form when done.

 

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