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