Contact Information
Penn State Behrend Health 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 Center. When possible, include a photocopy of the front and back sides 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: