Fill out the information below to get started right away. We’ll be in contact soon. Our specialists look forward to working with you!

Of note: The information requested is that which is necessary to create a profile for you in our medical records system.

All information is kept confidential

Summit Physical Therapy accepts most major insurance plans (including Medicare but not state plans/Medicaid at this time.) As a free courtesy, we are happy to contact your insurance company and check your insurance benefits for you. Within 24-48 hours we will be able to give you a breakdown of what your plan covers.

Note: If you are submitting a request for ONERO training or Personal Training, you do not need to fill out insurance information.

Name

First Name

Last Name

Email

Phone

(###)

###

####

Date of Birth

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

How Can We Help You?

Do You Prefer That We Contact You Via Phone, Email, or Both?

Phone Call

Email

Do you have a preference of being scheduled with only a male or female therapist?

Male only

Female only

No Preference

If you are coming to us for personal training, there is no need to fill out insurance information below. If you are coming for physical therapy, we accept most major insurance plans, including Medicare, (we do not accept state plans/medicaid at this time) and will check your benefits free of charge for you.

Do you have a primary care or referring physician? If so, please include their name below

If someone else is the primary person on the insurance plan (e.g. a parent, spouse etc.) please include their full name below. (Leave blank if you are the primary)

If someone else is the primary person on the insurance plan, please include their birthdate below (leave blank if you are primary)

Insurance Company (e.g. Carefirst, Cigna), and plan name (e.g. FEP Basic, Blue Choice, Silver PPO)

Member ID and Group number (if applicable)

Insurance Phone Number (Provider line, listed on back of your card)

(###)

###

####

Prefer phone? Call us directly at 410.995.8178 (option 1) and we’ll get you squared away for your evaluation and answer any questions you may have. If we’re unable to pick up, please leave a voicemail with your contact info and we’ll be in touch right away!

We look forward to working with you!