HID Dispensing Contract Forms

Department staff is often asked to review dispenser contracts for the sale of hearing instruments and give guidance on compliance with legal requirements. In addition, many complaints arise from the dispenser–purchaser transaction.

As an aid to dispensers and to address the many problems the Department sees in the contracts used in dispensing transactions, the five forms described below are provided for dispenser use with potential and actual hearing instrument purchasers.

These forms were developed by a working group of Hearing Instrument Dispensers, Audiologists, consumers, manufacturer representatives and Department staff. Use of the forms is not required, but as the forms may assure legal requirements are met and may promote greater satisfaction of hearing instrument purchasers, Department staff highly recommend their use.

Hearing Evaluation, Audiogram, Recommendation and FDA Wavier (pdf#1:81k:legal size)
This form includes a check box for client receipt of the MDH brochure and audiogram, a check box for practitioner’s confirmation of the FDA Screen, the practitioner’s recommendation and the required language regarding consumer choice.

Hearing Instrument Purchase Agreement (pdf#2:18k:letter size)
This form can be used with Form #1 when the consumer agrees to purchase the hearing instrument as recommended by the practitioner. The form includes required purchase agreement contract language, but excludes the audiogram and language on consumer choice.

Hearing Instrument Recommendation and FDA Waiver (pdf#3:18k:letter size)
This form does not include the audiogram results and can be used by practitioners who prefer to attach a copy of the audiogram to the recommendation. The form includes the check box for client receipt of the MDH brochure and audiogram, a checkbox for the practitioner’s confirmation of the FDA screen, the practitioner’s recommendation and the required language regarding consumer choice.

Hearing Instrument Recommendation and Purchase Agreement (pdf#4:18k:legal size)
This form includes the required language for consumer choice and includes the required purchase agreement contract language.

Home Solicitation Sales Purchase Agreement (pdf#5:17k:legal size)
This form includes the required purchase agreement contract language with a tear-off section at the bottom for in-home sales that complies with Minn. Stat. (2008) sections 325G.06-325G.14

Questions? Please call the Health Occupations Program at 651-201-3729 and press 3 to speak with a staff person.

Updated Wednesday, 19-Oct-2011 10:41:32 CDT