Hearing Instrument Dispenser Complaint Form
To assist you with your complaint, the Minnesota Department of Health asks that you complete this form and submit it, with your written statement, via U.S. Mail to:Minnesota Department of Health
Hearing Instrument Dispensers
P.O. Box 64882
St. Paul, Minnesota 55164-0882
Instructions: Please type and print, or print and handwrite clearly, using blue ink. Sign, and mail in your completed forms.
Based on the information you provide, an investigation will be conducted. Please type, or print clearly, using black ink.
Narrative description of your complaint: Please describe what occurred, where and when the incident transpired and who was involved. Include in your narrative your relationship to the practitioner, where the practitioner was employed at the time of the incident, and any previous or subsequent encounters you may have had with the practitioner. If possible, please include the identities and phone numbers of anyone who may have either witnessed the incident or have additional information regarding either the incident or the practitioner. Please include copies of any supporting documents you may have. If you need more space, you may include additional pages. Please sign and date each narrative page. Your rights are described under the Tennessen Warning included with this form.
Additional Questions Relating to Hearing Instrument Dispensers:
Did the hearing aid dispenser also test your hearing? If no, who tested your hearing and when?
Was your hearing aid dispenser also an audiologist?
Did you purchase hearing aids in your home?
On what date did you sign purchase agreement?
On what date were your hearing aids delivered?
Did you see a medical doctor prior to purchasing the hearing aids? If yes, when did you see the doctor and did the doctor evaluate your hearing or ears?
How many hearing aids did you buy?
What type of hearing aid did you buy? Body Type: BTE (Behind the Ear), ITE (In the Ear), CIC (Completely in the canal)
What was the total purchase of your hearing aid(s)?