The following constitutes an agreement between undersigned patient or guarantor and David Schechter, MD. Dr. Schechter's offices are currently at 8530 Wilshire Blv'd, Ste 250, Beverly Hills, CA 90211. Fax there is 310 657 0466. Telephone 310 657 0366.

              Culver City location is 3855 Hughes Avenue, Culver City, CA 90232. Fax there is 310 838 3777. Phone 310 838 2225.

            ASSIGNMENT OF BENEFITS/FINANCIAL RESPONSIBILITY: I hereby authorize payment directly to the Provider. I understand that my insurance policy is a contract between myself and my insurance provider and that I am ultimately financially responsible for non-covered services. The Provider will file my insurance claim only as a courtesy.
          AUTHORIZATION TO RELEASE INFORMATION: I hereby authorize the Provider to release any information required to process my claim.

            I understand that if I have an appointment and fail to cancel it at least twenty-four hours in advance, during the business hours of this office, that I will be charged a $50 fee for the doctor's time.  I understand that insurance companies do not typically pay this fee and that this responsibility is mine alone.

Patient Name                                                            Parent or Legal Guardian, where appropriate

Primary insured                                                    Guarantor, name address, where appropriate

Date and Time