2026 New Patient Paperwork (Auto)

Patient Entrance History

Five Points Chiropractic ~ 920 S. Milledge Ave 2 Athens, GA 30605 ~ 706-546-7700 ~ www.FivePointsChiropractic.com
Signature*
First Name*
Middle
Last Name*
Address*
City*
State*
Two letter abbreviation
Zip*
Sex

MaleFemale
Marital Status

SingleMarriedDivorcedWidowedSeparated
Age*
Birthdate*

MonthDayYear
Date
Occupation
Employer
Employer address
Spouses Name
Occupation
Spouse's Employer
Names and ages of children
ASSIGNMENT AND RELEASE

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.
Responsible Party Signature*
Relationship (Self, Parent, Guardian)*
Date

MonthDayYear
Date
Phone Numbers
Home
Cell*
Work
Ext
May we contact you at work?

YesNo
Would you like appointment text reminders?

YesNo
Cell Phone Provider
Email Address
example@example.com
Accident Information
Is this condition due to an accident?*

YesNo
Date of Accident?*

MonthDayYear
Date
Type of Accident?*

AutoWorkHomeOther
To whom have you made a report of your accident?*

Auto InsEmployerWorkers CompOther
Attorney Name if applicable
IN CASE OF EMERGENCY, CONTACT
Name*
Home Phone*
Format: (000) 000-0000.
Work Phone
Format: (000) 000-0000.
Relationship
Patient Condition
Primary Concern*
When did your symptoms appear? *
Is this condition getting progressively worse?*

YesNoUnknown
Rate the severity of your pain on a scale of 1 least pain or 10 severe pain*
Type of pain? Check all that apply*

SoreDullAchingSharpStabbingBurningTinglingNumbnessOther
How often do you have this pain?*
Does it interfere with your:*

WorkSleepDaily RoutineRecreation
Activities or movements that are painful to perform:*

BendingLaying downSittingStanding
Activities or movements that make it feel better:*

Lying downSittingStandingRestMovement
What treatment have you already received for your condition?*

MedicationSurgeryPhysical therapyChiropracticNoneOther
HEALTH HISTORY
Please check any of the following symptoms you have experienced since your accident:*

Carpal Tunnel SyndromeCold/FluDifficulty BreathingDigestive ProblemsDizzinessFibromyalgiaHeadachesJoint ProblemsLeg & Hip ProblemsLoss of Energy/FatigueLow Back PainMid Back PainNeck PainSciaticaStiffnessStressed ShouldersTingling or NumnbnessTMJ ProblemsUpper Back PainNONE OF THE ABOVEOther
Have you ever been diagnosed or told you have one of the following diseases, disorders or medical conditions?*

AIDS/HIVAllergiesArthritisArtificial Bones/JointAsthmaCancer (answer below what kind)Chemical DependencyCongenital Heart DefectDiabetesEar InfectionsFainting/SeizuresGoutHearing ProblemsHeart AttackHepatitisHerniated DiscHigh/Low Blood PressureHigh CholesterolKidney ProblemsLiver DiseaseLoss of Bowel/Bladder ControlPacemakerScoliosisSinus ProblemsStrokeThyroid ProblemsTuberculosisUlcers/ColitisWhiplashNONE OF THE ABOVEOther
If answered "YES" to Cancer, what type?
MEDICAL HISTORY
Date of last MRI CTScan Bone Scan or other

MonthDayYear
Date
Name of Doctors who have treated you for your condition
Name of your Primary Physician
HABITS
Smoking?*

YesNo
If yes, how many packs/day?
Coffee/caffeine?*

YesNo
If yes, how many cups/day?
Alcohol?*

YesNo
If yes, how many drinks/week?
High Stress Level?*

YesNo
If so, reason?
EXERCISE
Exercise?*

NoneModerateDailyHeavy
WORK ACTIVITY
Work Activity?

SittingStandingLight laborHeavy laborComputerDriving
7 MEDICATIONS VITAMINS and SUPPLEMENTS: Name and purpose (if none, enter N/A)*
is there anything else which may help us to better understand your history which has not been discussed on this survey? PLEASE INCLUDE ANY SURGERIES HERE
Notice of Privacy Practices Acknowledgement

I understand that / 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 private 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.
INJURY HISTORY
Type of Accident*

Automobile CollisionWork AccidentHome AccidentOther
Date*

MonthDayYear
Date
Time

Hour Minutes

AM/PM Option
Accident Time (Hour)
Accident Time (Minutes)
AM or PM?

AMPM
State how accident happened in your own words*
What county/city did accident occur?*
ONLY IF WORK RELATED: List any equipment machinery and/or object related to the accident
What is your job title or activity
Has accident been reported to supervisor or employer?

Type option 1Type option 2
Name of person reported to:
Title
IF MOTOR VEHICLE RELATED: Were you-

DriverPassengerPedestrian
If passenger:

Front SeatBack Seat
What kind of vehicle were you in?

CarTruckMotorcycleOther
Size and type of vehicle
If passenger, were you sitting in:

FrontRight RearLeft Rear
Did your vehicle strike:

Other vehicle(s)SignTreeBridgeHedgeEmbankmentDeerOther
How fast were you going?
Did your vehicle go off the road?

YesNo
If so:

Into a ditchInto an embankment
How deep?
Was your vehicle hit by other vehicle(s)?

YesNo
If yes, what kind of vehicle hit yours?

CarTruckMotorcycleOther
Size and type of vehicle
Where was your vehicle hit?

FrontBackLeft sideRight side
What damage was done to your vehicle, inside?
What damage was done outside?
Do you have pictures of the involved automobile?

YesNo
Were you wearing a seatbelt?

YesNo
Shoulder harness on?

YesNo
Did you hit any part of your body during the collision, for example, head on dash, chest on steering wheel?

YesNo
If yes, what part and how?
Did airbags deploy?

YesNo
If yes:

FrontSide
COMPLETE THIS NEXT SECTION FOR *ALL* ACCIDENT TYPES
Immediately following the accident how did you feel?*
Were you unconscious?*

YesNo
Did you go to the hospital?*

YesNo
If so, when did you go?

At time of accidentNext dayOther
How did you get to hospital?

AmbulancePrivate transportation
Did the ambulance attendants place you in a neck collar?

YesNo
Did they put you in splints?

YesNo
Did they put you in a brace?

YesNo
Name of Hospital
Name of Doctor
Were you x-rayed at the hospital?

YesNo
If so, what was your diagnosis?
Were you admitted to the hospital?

YesNo
What treatment was rendered?
How long was your stay?
What recommendations were made?
Have you seen any other doctors as a result of this accident?*

YesNo
If yes, who?
Have you lost any time from work because of this accident?*

YesNo
Have you returned to work since the accident?*

YesNo
Since the accident occurred, are your symptoms:*

ImprovingGetting worseSame
Do you notice any activity restrictions as a result of this injury?*

YesNo
If yes, please describe:
Have you ever been injured in a similar manner?*

YesNo
If yes, how and when?
Have you had to have any outside help?*

YesNo
CAR ACCIDENT ONLY: Does it bother you to ride in a car now?

YesNo
If so, which one bothers you more?

As a driverAs a passenger
Signature
Relationship to Patient (Self, Guardian, etc)
NOTICE OF PRIVACY PRACTICE

This office is required to notify you in writing, that by law, we must maintain the privacy and confidentiality of your Personal Health Information. In addition we must provide you with written notice concerning your rights to gain access to your health information, and the potential circumstances under which, by law, or as dictated by our office policy, we are permitted to disclose information about you to a third party without your authorization. Below is a brief summary of these circumstances. If you would like a more detailed explanation, one will be provided to you. In addition, you will find we have placed several copies in report folders labeled 'HIPAA' on tables in the reception. Once you have read this notice, please sign the last page, and return only the signature page (page 2) to our front desk receptionist. Keep this page for your records.

PERMITTED DISCLOSURES

1. Treatment purposes- discussion with other health care providers involved in your care

2. Inadvertent disclosures- open treating area mean open discussion. If you need to speak privately to the doctor, please let our staff know so we can place you in a private consultation room.

3. For payment purposes - to obtain payment from your insurance company or any other collateral source.

4. For workers compensation purposes- to process a claim or aid in investigation

5. Emergency- in the event of a medical emergency we may notify a family member

6. For Public health and safety - in order to prevent or lessen a serious or eminent threat to the health or safety of a person or general public.

7. To Government agencies or Law enforcement - to identify or locate a suspect, fugitive, material witness or missing person.

8. For military, national security, prisoner and government benefits purposes.

9. Deceased persons -discussion with coroners and medical examiners in the event of a patient's death.

10. Telephone calls or emails and appointment reminders -we may call your home and leave messages regarding a missed appointment or apprize you of changes in practice hours or up-coming events.

11. Change of ownership- in the event this practice is sold, the new owners would have access to your PHI.

YOUR RIGHTS:

1. To receive an accounting of disclosures

2. To receive a paper copy of the comprehensive "Detail" Privacy Notice

3. To request mailings to an address different than residence

4. To request Restrictions on certain uses and disclosures and with whom we release information to, although we are not required to comply. If, however, we agree, the restriction will be in place until written notice of your intent to remove the restriction.

5. To inspect your records and receive one copy of your records at no charge, with notice in advance

6. To request amendments to information. However, like restrictions, we are not required to agree to them.

7. To obtain one copy of your records at no charge, when timely notice is provided (72 hours). X-rays are original records and you are therefore not entitled to them. If you would like us to outsource them to an imaging center, to have copies made, we will be happy to accommodate you. However, you will be responsible for this cost.

COMPLAINTS:

If you wish to make a formal complaint about how we handle your health information, please call the office manager at (706) 546-7700. If she/he is unavailable, you may make an appointment with our receptionist to see her/him within 72 hours or 3 working days. If you are still not satisfied with the manner in which this office handles your complaint, you can submit a formal complaint to:

DHHS, Office of Civil Rights

200 Independence Ave. SW

Room 509F HHH Building

Washington DC 20201
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.
Patient initials*
Patients Name*
DOB*
Signature
Date

MonthDayYear
Date
Should be Empty:

Phone Numbers

Accident Information

IN CASE OF EMERGENCY, CONTACT

Patient Condition

MEDICAL HISTORY

HABITS

EXERCISE

WORK ACTIVITY

INJURY HISTORY

COMPLETE THIS NEXT SECTION FOR *ALL* ACCIDENT TYPES

COMPLETE THIS NEXT SECTION FOR ALL ACCIDENT TYPES