Marketing Authorization

I hereby authorize BetaBionics to use or disclose my protected health information (“PHI”) as defined under the Health Insurance Portability and Accountability Act of 1996, as amended (“HIPAA”), and limited to my name, contact information and healthcare condition for the limited purposes of providing me with additional communications about treatment alternatives or other health related products or services provided by BetaBionics, our affiliates and/or vendor partners. I understand that this Marketing Authorization is voluntary. My failure to sign this Marketing Authorization or to later revoke this Marketing Authorization will not otherwise affect any treatment, payment, eligibility for benefits or enrollment activities that I am entitled to receive or participate in. The PHI used or disclosed based on my authorization may be re-disclosed by the recipient(s) and will no longer be protected by HIPAA. I understand that I may revoke my authorization at any time by sending an email to BetaBionics at marketing@betabionics.com. I understand that my revocation will be effective upon receipt, except to the extent that any party has acted in reliance on this Marketing Authorization.