DEPARMENT OF HEALTH
Alternate Hearing Aid Disclosure Agreement Form
[42 Pa.B. 7061]
[Saturday, November 10, 2012]
Under the Hearing Aid Sales Registration Law (act) (35 P. S. §§ 6700-101—6700-802), specifically section 207 of the act (35 P. S. § 6700-503.1), a disclosure agreement is required to be provided by a registrant (dealer or fitter holding a certificate of registration) to a consumer prior to the provision of any service. Further, 28 Pa. Code Chapter 25, Subchapter B (relating to hearing aid sales and registration), specifically 28 Pa. Code § 25.210(b) (relating to receipt, disclosure agreement and money back guarantee to purchaser—purchaser protection), provides the following guidance regarding the disclosure agreement requirement for registrants:Before the provision of any service incidental to or connected with the potential sale of a hearing aid, the registrant shall provide a disclosure agreement and money back written guarantee to the prospective hearing aid user or authorized representative, and shall explain it in detail in accordance with subsec-tion (c). This shall be in 10 point type or larger, and may be made out on more than one sheet of paper, but shall employ the following format or be on a form approved by the Department:
The ''Department'' as referenced in the previous regulation (28 Pa. Code § 25.210(b)) means the Department of Health. The Department of Health has approved the following Alternate Disclosure Agreement form as meeting the requirements of 28 Pa. Code § 25.210:
ALTERNATE HEARING AID DISCLOSURE AGREEMENT/MONEY BACK GUARANTEE
(Business Name) _________________ (Business Address) _________________
Telephone No. ( ) _________________
Description of services included in fitting procedure or process, and sale and delivery of hearing aid. FEE (State
whether fee is
(Upon return of hearing aids)
HEARING EVALUATIONS OR TESTS PERFORMED PRIOR TO THE DATE OF THIS AGREEMENT THAT WERE REIMBURSED BY A THIRD PARTY PAYOR ARE NOTED AS SERVICES PREVIOUSLY RENDERED AND BILLED TO THIRD PARTY PAYOR. NO ADDITIONAL FEE HAS BEEN CHARGED FOR THESE SERVICES.
THIS DISCLOSURE AGREEMENT WAS PROVIDED, PARTS A AND B WERE EXPLAINED, AND PART A (FEES FOR SERVICES NOT PART OF THE PRICE OF THE HEARING AID) WAS COMPLETED AT _____ (time) ON ______ (date), BEFORE ANY SERVICES WERE PROVIDED. PART B (CANCELLATION FEES THAT WILL BE INCURRED IF A HEARING AID IS RETURNED UNDER THE 30-DAY MONEY BACK GUARANTEE BELOW), WAS COMPLETED AND EXPLAINED AFTER SERVICES WERE PROVIDED AND BEFORE ANY PAYMENT WAS MADE. IF PART B IS NOT COMPLETED, IT IS BECAUSE A HEARING AID WAS NOT RECOMMENDED OR NOT DESIRED.
NOTHING IN THIS DISCLOSURE AGREEMENT SHALL RELIEVE A REGISTRANT OF THE OBLIGATION TO REFUND ALL OR PART OF THE ABOVE FEES, INCLUDING THOSE LISTED AS NOT REFUNDABLE, IF A COURT DETERMINES THAT THE REGISTRANT HAS VIOLATED A PENNSYLVANIA CONSUMER PROTECTION LAW IN THE SALE OR FITTING OF THE HEARING AID (OR SIMILAR DEVICE) AND IF THE COURT ORDERS SUCH REFUND.
Customer's Signature Registrant's Signature
HEARING AIDS &
DESCRIPTION of GOODS—include make, model, serial number(s) PRICE
(upon return of
Hearing Aid(s) Right Left Accessories (Describe, if
TOTAL Total maximum Cancellation Fee is lesser of 10% or $150 per hearing aid including accessories.
30 Day Money Back Guarantee: If a hearing aid is returned within 30 days of date of delivery in the same condition, ordinary wear and tear excluded, you are entitled to a refund of the portion of the purchase price of the hearing aid and accessories as itemized on the receipt and above, less the cancellation fee stated above. If a cancellation fee is imposed the nonrefundable amount for each aid and accessories cannot exceed 10% of the purchase price of the hearing aid and accessories or $150.00 per aid and accessories, whichever is less. You will, however, be responsible for all nonrefundable service fees listed in Part A. If you cancel your order prior to delivery, you are entitled to full refund of the purchase price of the aid and accessories, and a full refund for services not yet rendered.
_________________ _________________ _________________ Customer's Signature Date and time of Sale DATE of DELIVERY _________________ _________________ _________________ Registrant's Signature Registration No. Customer's Signature or Initials
The approval of the use of this Alternate Disclosure Agreement form is effective upon publication of this notice in the Pennsylvania Bulletin.
Persons with a disability who require an alternative format of this notice (for example, large print, audiotape, Braille) should contact the Department of Health, Bureau of Community Program Licensure and Certification, Division of Home Health by the Hearing Aid Program, 132A Kline Plaza, Harrisburg, PA 17104, (717) 783-1379, or for speech and/or hearing impaired persons V/TT (717) 783-6514, or the Pennsylvania AT&T Relay Services at (800) 654-5984.
[Pa.B. Doc. No. 12-2201. Filed for public inspection November 9, 2012, 9:00 a.m.]
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