THE PENNSYLVANIA STATE UNIVERSITY
MAINTENANCE PRESCRIPTION DRUG PLAN
ENROLLMENT FORM
1-800-821-7285
814-865-9321
University Health Services
Ritenour Building
Pharmacy Room 130
University Park, PA   16802

Patient Name    ________________________________    Social Security #___________________

 Home Address ________________________________________________________________________________                            Street                                       Town                                       State                             Zip

Date of Birth     _____________________________            Current Age     _________________

Relationship                  (  ) Employee                 (  ) Spouse            (  ) Child*

                                      (  )  Male                      (  ) Female

 Name of family doctor_______________________________________________________

 Known drug allergies________________________________________________________

 Rx packaging                 (  ) Safety Caps                            (  ) Non-Safety Caps

PSU Employee Name   ________________ PSU ID NUMBER __________________
OR SOCIAL SECURITY NUMBER ___________________

 Work Phone     ___________________________     Home Phone_____________________

 Campus Mailing Address______________________________________________________

 If changes in above information occur, a new form must be submitted.

 *    If child is NOT a full-time student, Rx coverage ceases at age 19.  If child is age 19 or older, and A        FULL-TIME STUDENT, coverage ceases at age 24.

Any person who knowingly files a statement containing any false information or conceals information for the purpose of misleading will be subject to disciplinary action.

 Employee’s Signature________________________________    Date ______________________