Healthcare Hearing Aid Receipt

HEARING AID RECEIPT AND DISPENSING ACKNOWLEDGMENT

Provider / Dispensing Facility

Patient Information

Patient Name:

Insurance / Payment Information

Medical / Hearing Background

Device / Dispensing Details

Receipt No.:    Delivery Date:

Side: Left Right    Condition: New Refurbished

Side: Left Right    Condition: New Refurbished

Accessories / Materials Provided

Please indicate items provided with the device:

Batteries    Charger    Domes / Tips    Wax guards

User manual / instructions    Carrying case    Cleaning kit    Custom molds

Device Programming / Initial Settings

Financial Transaction

Payment Method: Cash Check Credit Card Insurance Billing

By signing below, the patient or responsible party acknowledges responsibility for any charges not paid by insurance and authorizes assignment of benefits for services rendered where applicable. The patient acknowledges that coverage and benefits are determined by the insurer and that the provider bears no sole responsibility for coverage determinations.

Warranty, Return & Repair Policy

The dispensing clinic warrants that the device(s) delivered conform to the manufacturer's specifications and were functioning at the time of delivery. Warranty coverage, duration, and remedies are subject to the manufacturer's written warranty. Any warranty repair requests must be submitted in writing and are subject to warranty verification and the manufacturer's terms.

Return Policy: Patient may request evaluation for adjustment or return within the fitting trial period specified at the time of sale. Returns are conditional upon device inspection; devices with physical damage or evidence of misuse may be ineligible for return or subject to a restocking or refurbishment fee. Elective adjustments or repairs outside warranty may incur charges.

Warranty Expiration Date:

Acknowledgments & Patient Consent

I acknowledge receipt of the hearing aid(s), accessories and instructional materials listed above. I further acknowledge that the dispensing clinician demonstrated proper use, insertion, removal, cleaning, battery handling, and basic troubleshooting. I have been given the opportunity to ask questions and understand how to contact the clinic for follow-up care.

I understand that proper use and maintenance are my responsibility and that failure to follow instructions may void warranty or limit repair coverage. I consent to the clinic performing necessary adjustments and minor in-office repairs as permitted by law, and I authorize the release of billing information to my insurance carrier for payment purposes.

I acknowledge I received the device(s) and accessories listed.

I acknowledge I received verbal and written operating instructions and understand follow-up steps.

I acknowledge the clinic's return and trial period policy described above.

Privacy (HIPAA) Acknowledgment

I acknowledge that I have been offered a copy of the clinic's Notice of Privacy Practices describing how my health information may be used and disclosed. I understand that the clinic is permitted to use and disclose health information for treatment, payment, and healthcare operations in accordance with applicable law.

I acknowledge receipt of the Notice of Privacy Practices.

Additional Authorizations

Authorization to Release Information: I authorize the release of clinical and billing information to my insurance carrier or other designated payors to facilitate payment of benefits. This authorization expires on:

Patient Notes / Additional Instructions:

Sign Now