Exhibit 4

Atlanta Neurology

Receipt of Notice of Privacy Practices Written Acknowledgement Form

I, _______________________________, have received a copy of Atlanta Neurology's Notice of Privacy Practices.

_____________________________________
Signature of Patient

_____________________________________
Date

Please print this form, fill in the entries, sign, and return to the offices of Atlanta Neurology:
attn: Joan Tolleson
Atlanta Neurology
993-F Johnson Ferry Road
Suite 120
Atlanta, Georgia 30342