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