Michele Schneider MD, LLC              
Family Medicine  
33 Regency Plaza  
871 Baltimore Pike  
Glen Mills, PA 19342  
610-742-1500, Fax: 1-888-264-2168  
     
     
     
     
FINANCIAL RESPONSIBILITY AGREEMENT  
     
     
 
Please indicate with a checkmark that you have read each statement below.      
 
________ I authorize my insurance benefits be paid directly to Michele Schneider MD, LLC.    
     
________ I agree to pay any required co-payment at the time of service.  
 
________ I authorize the release of any information required to process my claims or as required by law.  
 
________ I understand that I am financially responsible for all services rendered, including co-payments, deductibles,
  and services not paid by insurance.  
 
________ I have had a chance to review the Notice of Privacy Practices.  I understand that this practice reserves the 
  right to change the terms of the Notice of Privacy Practices.  If changes to the policy occur, I will be provided 
  with a revised Notice of Privacy Practices upon request.  
 
 
Patient Signature             Date:    
           
                     
Patient Printed Name                
     
                     
Guarantor Signature (if other than patient)         Date:    
           
                     
Guarantor Printed Name           Relationship to Patient