Patient Authorization

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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.


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Step 1 of 7

14%
    The RNS System is for individuals 18 and older who have focal epilepsy and have tried two or more medications without finding seizure control.

  • Based on your answers, your patient might benefit from the RNS System.

    Get your profile and a list of questions to ask your doctor.

  • Unfortunately it appears your patient is not an appropriate candidate for the RNS® System at this time.

  • The RNS® System is intended for patients who have undergone diagnostic testing that localized no more than 2 epileptogenic foci.

    If your patient has not undergone diagnostic testing, search here to find a comprehensive epilepsy center that can evaluate your patient, including determining if the RNS System is right for them.

  • If you are interested in learning more about the RNS® System, you can have an RNS® System professional contact you by filling out the form below:

  • By filling out this form, you are agreeing to the terms of our privacy policy. This form is intended for US residents only.

    By clicking submit, you are agreeing to receive communications from NeuroPace. You can unsubscribe at any time.

    * Required fileds

Share your Story: Terms and conditions

By filling out the form and submitting your story (and/or photograph), you are agreeing to the following:

  1. NeuroPace may review the information and any photographs you provide for potential publication on our website.
  2. If NeuroPace decides to use your story, we will contact you and ask you to sign a release for a version of your story to be used on the NeuroPace website, Facebook, Instagram, Twitter and/or LinkedIn. Unless you sign the release, we will not publish the story, your name, or the photographs you provided.
  3. Regardless of whether we publish your story, we will add your name and e-mail address to the NeuroPace email list to hear from us about product updates, upcoming events and other relevant information. We will not sell your information to third parties. 
  4. Our use of your information is subject to our Privacy Policy, which you can access here.
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