Midwest Neuroscience

• Home
• Physician
  • Charles D. Donohoe, M.D.
• Services
• Headache Care
  • Acute Neurologic Headache Center
  • Patient's Guide to OPEN MRI
• Patient Info
  • Hours and Telephone
  • What to Bring
  • Patient Forms
  • Privacy Practices
  • Payment and Insurance
  • Hospital Affiliations
• Contact
• Resources
  • Clinical Trials
  • Patient Education
  • Glossary

Midwest Neuroscience, PC
MD Imaging
17020 E. 40 Hwy
Suite 8
Independence, MO 64055
Tel: 816.373.3213
Fax: 816.373.6209
VIEW MAP >>

After hours emergency #:
913.599.7459

Monday-Friday
8:30am-3:30pm

  E-mail This

NOTICE OF PRIVACY PRACTICES ACKNOWLEDGEMENT

I understand that, under the Health Insurance Portability and Accountability Act of 1996 ("HIPAA"), I have certain rights to privacy regarding my protected health information. I understand that this information can and will be used to:

• Conduct, plan and direct my treatment and follow-up among the multiple healthcare providers who may be involved in that treatment directly and indirectly.
• Obtain payment from third-party payers.
• Conduct normal healthcare operations such as quality assessments and physician certifications.

I have received, read and understand your Notice of Privacy Practices containing a more complete description of the uses and disclosures of my health information. I understand that this organization has the right to charge its Notice of Privacy Practices from time to time and that I may contact this organization at any time at the address above to obtain a current copy of the Notice of Private Practices.

I 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.

Patient Name:
Relationship to Patient:
Signature:
Date:

---

OFFICE USE ONLY

I attempted to obtain the patient's signature in acknowledgement on this Notice of Privacy Practices Acknowledgement, but was unable to do so as documented below:

Date:

Initials:

Reason:

Midwest Neuroscience offers the Acute Neurologic Headache Center for addressing your head pain concerns:

• Menstrual migraine
• Migraine / cluster headaches
• Tension headaches
• Facial pain / trigeminal neuralgia
• Cervical / spinal pain

"It's not just all in your head."

Take our quiz: How much are headaches affecting your life?