Why Midwest | Midwest Ear, Nose & Throat Specialists

Tell others why you’ve made Midwest a part of your health care team.

Thank you for considering sharing your personal story with others. Your health care journey represents a lot of learning, decision making and courage on your part. Your experience can provide powerful inspiration, encouragement, and information as others travel a similar path.

We invite you to share your story in the form below. We were pleased to be a part of it and we will be honored to make your story known.

Name(Required)

Email(Required)

Provider

Recdiver

Message(Required)

File

Max. file size: 64 MB.

Would you like to share a photo?

Image acknowledgement(Required)

Photos, videos, and/or likeness of me in marketing and advertising materials.

Verbal Acknowledgemnet(Required)

Verbal and/or written testimonial related to my treatment.

Photo Ack(Required)

I acknowledge I am submitting this testimonial and or photos on behalf of myself and no one else.

Revoke Statement(Required)

I understand that I may revoke this authorization by sending a written request for revocation to Midwest Ear, Nose & Throat Specialists. If I revoke this authorization, Midwest will no longer use or disclose my medical information for the reasons covered by this authorization, except to the extent it has already relied upon this authorization. I understand that when Midwest Ear, Nose & Throat Specialists discloses information pursuant to this authorization, the information may no longer be protected by federal or state privacy rules and may be subject to re-disclosure by the recipient of the information.

Not Expire(Required)

This authorization shall not expire unless requested by Patient or Patient Representative.

Please prove you are human by selecting the Icon

Unless I otherwise specify, the information described above may be disclosed to Midwest’s vendors and/or to the general public in connection with publicizing and promoting Midwest, including in print publications, multimedia presentations, television advertising, on websites and social media sites, in any other distribution media, and educational materials.

I understand that Midwest will not condition treatment, payment, enrollment or eligibility for benefits on whether I sign this authorization form.

I understand that I may revoke this authorization by sending a written request for revocation to Midwest’s Privacy Officer. If I revoke this authorization, Midwest will no longer use or disclose my medical information for the reasons covered by this authorization, except to the extent it has already relied upon this authorization. I understand that when Midwest discloses information pursuant to this authorization, the information may no longer be protected by federal or state privacy rules and may be subject to re-disclosure by the recipient of the information.

This authorization shall not expire unless requested by Patient or Patient Representative.

Midwest Ear, Nose & Throat Specialists (Midwest) is a group of local medical practices, independently owned and led by its physicians, with operating divisions representing several areas of expertise. Visit mwent.net to view the practices that are a part of Midwest.