It's easy to become a Premier Years member. Simply complete this application form. You can print it out and drop it in the mail to Premier Years, Albert Einstein Healthcare Network, 5501 Old York Road, Philadelphia, PA 19141, or submit it electronically. If you prefer, you may also enroll over the telephone by calling (215) 456-7800.

First Name
Last Name
Salutation	Mr. Mrs. Ms. Dr. Rev.
Date of Birth
Female	Male
E-mail Address
Marital Status	Married Single/Divorced Widowed
Street Address
City
State
Zip
Telephone
Do you have a primary care doctor?
Yes	No
Which hospital do you use most often?
Have you ever or are you currently using Albert Einstein Healthcare Network services?
Yes	No
If yes, which hospitals?
Albert Einstein Medical Center Belmont Behavioral Health Einstein at Elkins Park Einstein Center One Germantown Community Health Services MossRehab Willowcrest Willow Terrace

Because we value the relationship we have with you, Albert Einstein Healthcare Network does not share or sell this information to any outside organizations. However, this form is not on a secure server, and your information could be viewed by an outside source.