1. 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. 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. 3. The expected results of the goods and services are:

4. 4. If the goods to be provided include a hearing instrument:

   1. (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.

   2. (b) You have the right to receive a written receipt or

      1. (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.

      2. (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.

      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.

5. 5. If the goods and services provided do not substantially

   1. (a) necessary intervention to produce satisfactory recovery

      results consistent with the representations made above at no

      additional cost; or

   2. (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

   enhance your hearing as stated in the expected results, you

   are entitled to:

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.

KEY: licensing, hearing aids, hearing instrument specialist, hearing instrument intern

Date of Last Change: December 11, 2023

Notice of Continuation: October 2, 2023

Authorizing, and Implemented or Interpreted Law: 58-1-106(1)(a); 58-1-202(1)(a); 58-46a-101; 58-46a-304