R156-46a-502d. Form of Written Informed Consent

  In accordance with 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 Ann. Sections 58-46a-502

 and 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 specialist 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 commence 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 of time after finding that the

hearing instrument does not substantially enhance your hearing.

I hereby acknowledge being informed of the above and consent

to the receive the goods and services.

Patient's Signature and Date