Text Size:   A+ A- A   •   Text Only
Find     
Site Image
Statement to Prospective Purchaser
Requirements for Licensees
Following is required content and specifications for the Statement to Prospective Purchaser, which is required “…prior to consummation of a sale of a hearing aid….” under Oregon Revised Statutes (ORS) 694.036.  Requirements are also taken from Oregon Administrative Rules (OAR) 331-640-0030. 
 
 
Paper/Type Specifications
  • 8 ½” x 11” paper
  • No smaller than 10-point type

 
Licensee Information
  • Licensee name
  • Licensee address
  • Licensee telephone number
  • Licensee license number
  • Licensee signature

 
Purchaser Information
  • Purchaser name
  • Purchaser address
  • Purchaser signature

 
Medical Waiver Information
  • In 10-point type the following bordered statement:
 
 “It is desirable that a person seeking help with a hearing problem (especially for the first time) consult an ear doctor and obtain a clinical hearing evaluation. Although hearing aids are often recommended for hearing problems, another form of treatment may be necessary.”

 
Waiver of Medical Opinion
If the purchaser refuses to see a physician before purchasing a hearing aid, a Waiver of Medical Opinion must be completed which states, “I do not desire to have a medical evaluation before purchasing a hearing aid.” Required waiver information includes:
  • Name of licensee
  • License number
  • Purchaser’s name
  • Purchaser’s address
  • Purchaser’s signature and date

 
Hearing Aid Information
  • Specifications as to the make, serial number and model number of the hearing aid or aids sold

  • Description of the hearing aid – new/used, demonstration instrument or reconditioned

 
Purchase / Delivery
  • Purchase price
  • Refund amount (if any)
  • Trade-in amount (if any)
  • Cost of the hearing aid(s) and all related fees
  • Date of sale
  • Delivery date of hearing aid(s)

 
Rescission / Cancellation
  • Date 30-day rescission period ends

  • Portion of the total purchase price that will be retained by the licensee

  • Date of post-delivery follow-up session and any changes made to agreed-upon date

  • Place of post-delivery follow-up session and any changes to agreed-upon location

  • Printed or reproduced copy of ORS 694.042 Right to Rescind a Hearing Aid Purchase in its entirety, which includes the procedures for returning the hearing aid(s) to the licensee

 
Audiogram / Test Results
  • The following statement, initialed by the purchaser:  “Copies of my audiogram and the results of tests or verification procedures were offered to me by the licensee, and I hereby acknowledge receipt of the records or that I declined the offer.”

 
Consumer Protection/Complaints
  • The following statement about filing complaints:  “Complaints regarding the sale, lease, or attempted sale or lease of hearing aids should be directed in writing to:  Oregon Health Licensing Agency, 700 Summer Street NE, Suite 320, Salem, OR  97301-1287. Complaint forms may be obtained by calling 503-378-8667 or at the agency’s website at www.oregon.gov/OHLA

 
Purchaser Acknowledgement
  • A statement acknowledging that the purchaser has read and understands the information contained in the statement

  • Purchaser signature

  • Date purchaser signed statement

 
In-Home Sales Cancellation
The in-home sales notice of cancellation must include (in-home sales only):
  • Federal guidelines for in home sales
  • Name of licensee
  • Name of licensee’s business
  • Signature and date of purchaser
  • Name of licensee’s business
  • Signature and date of purchaser
 

 
For More Information
OHLA
For more information, contact the Oregon Health Licensing Agency (OHLA) at 503-378-8667 or ohla.info@state.or.us