By signing this form, I authorize and give my consent to any and all of my health care providers to use and share my health information with MicroTransponder®, Inc. and its employees, agents and assigns ("MTI") as described below.

HEALTH INFORMATION TO BE USED AND SHARED

Identifiers, contact details, and insurance information:

• Full name, address, phone number, email address
• Date of birth
• Gender
• Device identifiers and serial numbers
• Any information I provide in this consent form
• Information input into your device Insurance information (EOBs, claims, etc.)

Device data (for example):

• Usage data
• Error logs
• Device setting and battery status
• Programming history

Medical records related to my condition and MTI products (for example):

• Health condition and clinical information
• Provider records, charts, and notes
• Diagnosis
• Correspondence
• Tests and test results
• Laboratory or X-ray records and reports
• Rehabilitation therapy records
• Provider notes

HOW MY HEALTH INFORMATION WILL BE USED AFTER SHARING

I authorize the use and sharing my health information for:

• Product-related support and maintenance. MTI may receive information from my providers, and communicate with me and my providers, about Vivistim® and my health and condition, including for purposes such as scheduling appointments, device maintenance, technical support, and battery end-of-service notifications.
• Product analytics. MTI may collect and analyze device and related data for product and service improvement and development.
• MTI to contact me about Vivistim. MTI may contact me by phone, email, or text messaging to provide me with information about MTI products and services. I will be able to opt-out of marketing communications at any time.
• Prior authorization/appeal support. If necessary, MTI may receive my insurance and medical information from my providers and use it for prior authorization and appeal support.

IMPORTANT INFORMATION

Right to cancel. I understand that I have a right to revoke this authorization at any time with written notice to info@microtransponder.com and that, unless revoked sooner, expires fifteen (15) years from the date the authorization is signed. I understand any actions already taken based on this authorization will NOT be affected.

Risk of redisclosure. I understand that any disclosure of my health information carries with it the potential for re-disclosure and that after disclosure my health information may not be protected by Federal or state privacy rules.

My choice. I understand that can choose not to sign this authorization and consent and that my provider(s) may not condition treatment, payment, enrollment, or eligibility for benefits on whether I sign this form.

My signature below acknowledges that I have read and understand this form, and I consent to the sharing and use of my information as described above.