Health Insurance Collection Form

Health Insurance Collection Form

Contact Information

Penn State Behrend Health and Wellness Center
4701 College Drive
Erie, PA 16563
Phone: 814-898-6217

Fax: 814-898-6924

 

Instructions:

Please return the completed form to the Penn State Behrend Health and Wellness Center. When possible, include a photocopy of the front and back side of your health insurance card(s).

 

Patient Information


Patient Name:

 

Patient PSU ID#:

 

Patient Date of Birth:

 

Insurance Information


Primary Health Insurance Company Name:

 

Policy/Member ID#:

 

Subscriber Name and Date of Birth:

 

Insurance Company Phone Number: 

 

Secondary Health Insurance Company Name: 


Policy/Member ID#:

 

Subscriber Name and Date of Birth:

 

Insurance Company Phone Number: