I understand that protected health information (PHI) will be disclosed to LivaNova and its agents for the purposes of insurance verification, preauthorization, predetermination, PCP referral assistance, and appeals; evaluating whether I am a candidate for Vagus Nerve Stimulation (VNS) Therapy; for ongoing maintenance and consultation by LivaNova regarding VNS Therapy; and contacting me for purposes of providing education regarding VNS Therapy. 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 submit this webform. By submitting this information, you agree to the Terms of Use outlined on this site.