VNS Therapy™ Patient Authorization Form

VNS Therapy™ Patient Authorization Form

Thank you for your interest in VNS Therapy™. Please provide the required information below, and a member of the VNS Therapy™ Patient Team will contact you.
Patient Information

Please provide the required information below.
Name*

First NameLast Name
Phone Number*
Email*
example@example.com
Patient / Legal Guardian E-Signature*

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Authorization*

I authorize the use and disclosure of my health information to LivaNova and its agents for the purposes of insurance verification, preauthorization, predetermination, PCP referral assistance, and appeals; ongoing maintenance and consultation by LivaNova regarding VNS Therapy; and contacting me to provide education regarding VNS Therapy. I understand that the health information disclosed to LivaNova may include, but not be limited to, insurance information, my name, phone number, diagnostic information, programming history, and medical history. While I understand that LivaNova commits to maintain the confidentiality of this information, I recognize that any disclosure of information carries the potential for unauthorized re-disclosure which may not be protected by applicable privacy laws. I understand that I may revoke this Authorization in writing at any time (except to the extent that LivaNova has already relied on this Authorization) by sending or faxing a written notice of revocation to LivaNova. I understand that this Authorization, unless sooner revoked, expires fifteen (15) years from the date I sign the Authorization. I may refuse to sign this form.