Five Points Chiropractic~ 920 5. Milledge Ave~ Athens, GA 30605 ~ 706-546-7700 ~ www.FivePointsChiropractic.com

I, the undersigned certify that I (or my dependent) have insurance
coverage with above named insurance company and assign directly
to Dr. Huppert all insurance benefits, if any, otherwise payable to me
for services rendered. I understand that I am financially responsible
for all charges whether or not paid by insurance. I understand that I
am financially responsible for all charges if I do not have insurance. I
hereby authorize the doctor to release all information necessary to
secure the payment of benefits. I authorize the use of this signature
on all insurance submissions.

Please identify how your current condition is affecting your ability to carry out activities that are routinely part of your life:

Notice of Privacy Practices Acknowledgement

I understand that I have certain rights of privacy regarding my protected health information, under the Health Insurance Portability & Accountability Act of 1996 (HIPAA). I understand that this information can and will be used to
1. Conduct, plan and direct my treatment and follow-up among the multiple healthcare providers who may be involved in that treatment directly and indirectly.
2. Obtain payment from third-party payers.
3. Conduct normal healthcare operations, such as quality assessments and physician certifications.

I acknowledge that I may request your NOTICE OF PRIVACY PRACTICES containing a more complete description of the uses and disclosures of my health information. I also understand that I may request in writing that you restrict how my pdvate information is used or disclosed to carry out treatment, payment, or health care operations. I also understand you are not required to agree to my requested restrictions, but if you do agree, then you are bound to abide by such restrictions.

Five Points Chiropractic's NOTICE REGARDING YOUR RIGHT TO PRIVACY continued

I have received a copy of Five Points Chiropractic's Patient Privacy Notice. I understand my rights as well as the practices duty to protect my health information, and have conveyed my understanding of these rights and duties to the doctor. I further understand that this office reserves the right to amend this 'Notice of Privacy Practice" at any time in the future and will make the new provisions effective for all information that it maintains past and present.

I am aware that a more comprehensive version of this "Notice" is available to me and several copies kept in the reception area. At this time, I do not have any questions regarding my rights or any of the information I have received.

When a patient seeks chiropractic health care and we accept a patient for such care, it is essential for both to be working for the same objective. Chiropractic has only one goal. It is important that each patient understands both the objective and the method that will be used to attain it. This will prevent any confusion or disappointment.

Adjustment: The adjustment is the specific application of forces to facilitate the body's correction of vertebral subluxation. Our chiropractic method of correction is by specific adjustments of the spine. Health: The state of optimal physical, mental and social well being, not merely the absence of disease or symptoms. Vertebral subluxation: A misalignment of one or more of the 24 vertebra in the spinal column which causes alteration of nerve function and interference to the transmission of mental impulses, resulting in a lessening of the body's ability to express its maximum health potential.

We do not offer diagnosis or treat any disease. We only offer to diagnosis either vertebral subluxations or neuro­-musculoskeletal conditions. However, if during the course of a chiropractic spinal examination we encounter non­ chiropractic or unusual findings, we will advise you. If you desire advice, diagnosis or treatment for those findings, we will recommend that you seek the services of another health care provider.

Regardless of what the disease is called, we do not offer to treat it. Nor do we offer advice regarding treatment prescribed by others. OUR ONLY PRACTICE OBJECTIVE is to eliminate major interference to the expression of the body's by others. healing wisdom. Our only method is specific adjusting to correct vertebral subluxations. However, we may use other procedures to help your body hold the adjustments.

Today's appointment will consist of the consultation, examination, possible x-rays. The doctors will then review all findings and schedule a special appointment time in which they will explain in detail the results of your examination and go over your personal care plan. That appointment is called your Report of Findings. We prefer that you schedule this appointment within one week of today's appointment. There is no fee for your Report of Findings.