Michele Schneider MD, LLC              
Family Medicine  
33 Regency Plaza  
871 Baltimore Pike  
Glen Mills, PA 19342  
610-742-1500, Fax: 1-888-264-2168  
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.  
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