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