I hereby authorize, Dr. Mahendra Mahatma's office to release written or verbal information to my doctor or insurance carrier, should information be requested. In consideration of services rendered, I hereby assign to Dr. Mahatma, benefit payments due from my insurance company for medical expenses incurred which are payable to me.
Payment is due at time of service! This includes all copays, deductibles, and any other non-covered items.
I have been informed of or received a copy of the "Privacy Notice".
A $25 fee will be charged for all "NO SHOW" appointments not cancelled at least 24 hours in advance.