Utah Admin. Code 156-46a-502d
Under Subsection 58-46a-502(4)(c), an agreement to provide hearing instrument specialist goods and services shall include the patient's informed consent in substantially the following form.
TABLE
ACKNOWLEDGEMENT OF INFORMED CONSENT
As a consumer of hearing instrument specialist goods or services, you are required to be informed of certain information as provided in Utah Code Sections 58-46a-502 and 58-46a-503. |
1. The list of goods and services to be provided to you include the following: (add additional lines as required) |
Services: Charge: |
Goods (circle as applicable: new, used, reconditioned): Charge: |
These goods (circle as applicable: are, are not) covered by a warranty or guarantee. Additional information about any warranty or guarantee is attached. |
2. The licensees providing these goods and services are: (add additional lines as required) hearing instrument specialist: |
name: license number: |
hearing instrument intern |
name: license number: |
3. The expected results of the goods and services are: |
4. If the goods to be provided include a hearing instrument: |
(a) Additional information is attached about hearing instruments that work with assisted listening systems that are compliant with ADA Standards for Accessible Design adopted by the United States Department of Justice in accordance with the American with Disabilities Act, 42 U.S.C. Sec. 12101 et seq. |
(b) You have the right to receive a written receipt or written contract, which includes notice to you that you have a 30-day right to cancel the purchase and obtain a refund if you find the hearing aid does not function adequately for you. |
(i) The 30-day right to cancel shall start from either the date the hearing aid is originally delivered to you or the date the written receipt or contract is delivered to you, whichever is later. The 30-day period shall be tolled for any period during which the hearing aid seller, dealer, or fitter has possession or control of the hearing aid after its original delivery. |
(ii) Upon exercise of the 30-day right to cancel a hearing aid purchase, the seller of the hearing aid is entitled to a cancellation fee not to exceed 15% of all fees charged to the consumer, including testing, fitting, counseling, and the purchase price of the hearing aid. The exact amount of the cancellation fee shall be stated in the written receipt or contract provided to the consumer. |
5. If the goods and services provided do not substantially enhance your hearing as stated in the expected results, you are entitled to: |
(a) necessary intervention to produce satisfactory recovery results consistent with the representations made above at no additional cost; or |
(b) refund of the fees you paid for the hearing instrument within a reasonable period after finding that the hearing instrument does not substantially enhance your hearing. I hereby acknowledge being informed of the above and consent to receive the goods and services. Patient's Signature and Date |
Utah Admin. Code R156-46a-502d