73010 El Paseo, Suite 2B | Palm Desert, CA 92260
442-234-5364 | HerelTherapy@gmail.com
Consent, Financial Policy & HIPAA Notice
Consent to Treatment
Physical therapy at Herel PT may include therapeutic exercises, manual therapy, and other modalities. As with all medical treatment, there are benefits and risks. We cannot guarantee specific outcomes, and your responses to treatment may vary. You have the right to ask about your treatment plan and to decline any portion at any time.
I authorize Herel Physical Therapy to provide treatment to me.
I understand I am financially responsible for all charges, regardless of insurance coverage.
I authorize contact via my mobile number for appointments and account matters.
I understand there is a risk that treatment may cause temporary discomfort or may aggravate pre-existing conditions.
Patient / Guardian Signature
Printed Name
Date
Financial Policy
It is your responsibility to understand your insurance benefits. While we will file claims as a courtesy, all charges are ultimately your responsibility.
Co-pays are due at the time of service.
If you approach a visit limit requiring insurance authorization, you may be responsible for uncovered visits.
Accurate and up-to-date insurance information is required. Changes in coverage must be reported promptly.
Fee-for-service (non-insurance) payments cannot be submitted to insurance for reimbursement.
Unpaid balances may be sent to a collections agency if unresolved.
Insurance Provider
Member ID
Group Number
Patient / Guardian Signature
Printed Name
Date
HIPAA Notice of Privacy Practices
Your health information is protected under HIPAA. We will only share your information as necessary to provide treatment, process billing, or as required by law. You have the right to request access to your records at any time.
I acknowledge receipt of Herel Physical Therapy's HIPAA Notice of Privacy Practices.