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.

    We are also located in Regency Plaza, Glen Mills, PA, at the intersection of Routes 1 and 322.

    Locations

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

    Fountain Health, Inc.
    17 Regency Plaza,
    Glen Mills, PA 19342

    Contact Info

    Hours of Operation

    Monday: 10am – 7pm
    Tuesday: 10am – 6pm
    Wednesday: 10am – 6pm
    Thursday: 10am – 6pm
    Friday: 10am – 6pm
    Saturday: Closed
    Sunday: Closed

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