Patient Authorization for Physician to Disclose Information to NeuroPace, Inc. 

I authorize my physician to share with NeuroPace, Inc. (“Company”) information from the medical records my physician is maintaining for me, including my protected health information (e.g., medical history, diagnosis, and health insurance information) and contact information (e.g., name, phone number, and email address), so that NeuroPace can contact me with information, including educational information about the RNS System, to help determine if the NeuroPace RNS System may be right for me.

  • I understand that my physician and the institution with which my physician is affiliated may not condition treatment, payment, enrollment, or eligibility for benefits on whether I sign this Authorization.
  • I understand that information disclosed pursuant to this Authorization may be subject to redisclosure by the recipient and no longer protected by the Health Insurance Portability and Accountability Act ("HIPAA").
  • I understand that I may revoke this Authorization except to the extent my physician has already relied on it and shared my information with NeuroPace. I understand that if I want to revoke, I must do so in writing by sending a notice of revocation to my physician or physician's institution (to an address provided my physician).

By submitting this form, I give permission for NeuroPace to contact me via phone, email, or text message, which I can opt out of at any time. NeuroPace will never sell my data or personal information, and I agree to the Company's privacy policy. I also authorize NeuroPace to release my information to my health insurance provider to assess coverage of the RNS System and associated services.