R156-41-602. Form of Written Informed Consent

  (1) In accordance with Section 58-41-17, a speech-language pathologist or audiologist licensed under this chapter who offers to sell a hearing aid to a consumer shall include the patient's informed consent in substantially the following form.

TABLE

ACKNOWLEDGEMENT OF INFORMED CONSENT

As a consumer of a hearing aid, you are required to be informed

of certain information as provided in Section 58-41-17 of the

Utah Code.

1. I (the consumer) have been informed regarding hearing aids

that work with assistive listening systems that are compliant

with the ADA Standards for Accessible Design adopted by the

United States Department of Justice in accordance with the

Americans with Disabilities Act, 42 U.S.C. Sec. 12101 et seq.

2. I (the consumer) have been provided with a written receipt

or a written contract that provides the consumer with a 30-day

right to cancel the purchase and to obtain a refund if the

consumer returns the hearing aid to the seller in the same

condition as when purchased, excluding ordinary wear and tear.

I hereby acknowledge being informed of the above and consent

to the receive the hearing aid.

Patient's Signature and Date

Patient's Authorized Representative Signature and Date

Relationship to Patient

  (2) A patient's informed consent form shall meet the following requirements:

  (a) The 30-day written receipt or contract shall be written in at least 12-point font.

  (b) The 30-day right to cancel shall commence from the date the hearing aid is originally delivered to the consumer or the date the written receipt or contract is delivered to the consumer, whichever is later.

  (c) 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 deliver.

  (d) 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 equal to the actual cost that will be incurred by the seller in order to return the hearing aid to the manufacturer, provided that the written receipt or contract states the exact amount that will be retained by the seller as a cancellation fee.