Utah Admin. Code 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. 1210 1et 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 Authorize d 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.
Notes
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