Payment / Finance, Policies and Procedure Agreement:
(Please initial after each line and sign on the bottom)
Kishore Sunkara M.D.
669 Airport Frwy #401
Hurst, TX 76053
Patient Name
*
First Name
Last Name
Parent/Guardian Name
First Name
Last Name
I understand that this office requires updated payment information which I will be asked for when making my first appointment.
*
Initial
I understand that this information will be used for copays, future balances including No-Show charges.
*
Initial
I understand that I will be responsible for full amount of payment for services rendered that may not be covered by my insurance.
*
Initial
I understand that due to security reasons, I will provide updated payment information when necessary by phone or in person.
*
Initial
I read all the policies and procedures and agree
*
Initial
Signature of of patient / parent / guardian
*
Date
*
/
Month
/
Day
Year
Date
Submit
Should be Empty: