Patient Authorization for Release and Use of Health Information

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.

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 settings 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
• Physical therapy records
• Provider notes

I authorize the use and sharing of 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.

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 I 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.

**Only representatives with legal authority for healthcare decisions may sign on a patient's behalf. Please complete section below if you are the Legal Authorized Representative.