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 Name:

 

Patient PSU ID# and Date of Birth:

 

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: