Patient Registration Form

PATIENT INFORMATION - Please complete ALL relevant information *

Your Contact Information *

Patient Date of Birth:

Marital Status: Is Patient a Student? Work Related:

If Referred:

 

SUBSCRIBER/GUARANTOR INFORMATION (Person Responsible for Payment):

Date of Birth:

Patient's Relationship to Subscriber/Guarantor:

 

SUBSCRIBER/GUARANTOR EMPLOYER INFORMATION:

 

SUBSCRIBER/GUARANTOR/INSURANCE INFORMATION:

Date of Birth:

(If you have Medicare as secondary insurance - STOP and inform us immediately)

 

SECONDARY INSURANCE INFORMATION:

Date of Birth:

 

AUTHORIZATION TO PAY BENEFITS AND RELEASE INFORMATION TO FOUNTAIN HEALTH, INC: I hereby authorize payment directly to the undersigned physician for all medical benefits. I understand that I am financially responsible for charges not covered by my insurance carrier. I also authorize the undersigned physician release of any information acquired in the course of my examination or treatment.

Patient Signature:

 

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Fountain Health, Inc.

We are conveniently located in Bensalem, Pennsylvania, with easy access from I-95, PA Turnpike, and Route I.

Location

Fountain Health, Inc.
3554 Hulmeville Road
Suite 106
Bensalem, PA 19020

Contact Info

Tel: (215) 639-3185
Fax: (215) 639-3184
Email: info@fountainhealthinc.com
Email: myfountainhealth@gmail.com

Hours of Operation

Monday: 10am - 7pm
Tuesday - Friday: 10am - 6pm
Saturday: Closed
Sunday: Closed

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