Health Insurance Portability and Accountability Act (HIPAA)

Medical Waiver Form

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Please Note:

In accordance with the FDA rules, the HIPAA laws and for your safety, the following Patient Health History & Medical Waiver form is required to be completed prior to purchase of your hearing instruments.

The Following Information Is Required To Purchase Hearing Aids

First Name*:

Last Name*:

Company:

Address*:

City*:

State:
Alabama Aberdeenshire, SCT Alaska Alberta Alderney, CHI American Samoa Anglesey, WLS Angus, SCT Argyllshire, SCT Arizona Arkansas Armed Forces Abroad Armed Forces Americas Armed Forces Pacific Australian Capital Territory Avon, ENG Ayrshire, SCT Banffshire, SCT Bedfordshire, ENG Berkshire, ENG Berwickshire, SCT Borders, SCT Breconshire, WLS British Columbia Buckinghamshire, ENG Bute, SCT Caernarvonshire, WLS Caithness, SCT California Cambridgeshire, ENG Cardiganshire, WLS Carmarthenshire, WLS Central, SCT Channel Islands Cheshire, ENG Clackmannanshire, SCT Cleveland, ENG Clwyd, WLS Co. Antrim, NIR Co. Armagh, NIR Co. Carlow, IRL Co. Cavan, IRL Co. Clare, IRL Co. Cork, IRL Co. Donegal, IRL Co. Down, NIR Co. Dublin, IRL Co. Durham, ENG Co. Fermanagh, NIR Co. Galway, IRL Co. Kerry, IRL Co. Kildare, IRL Co. Kilkenny, IRL Co. Laois, IRL Co. Leitrim, IRL Co. Limerick, IRL Co. Londonderry, NIR Co. Longford, IRL Co. Louth, IRL Co. Mayo, IRL Co. Meath, IRL Co. Monaghan, IRL Co. Offaly, IRL Co. Roscommon, IRL Co. Sligo, IRL Co. Tipperary, IRL Co. Tyrone, NIR Co. Waterford, IRL Co. Westmeath, IRL Co. Wexford, IRL Co. Wicklow, IRL Colorado Connecticut Cornwall, ENG Cumberland, ENG Cumbria, ENG Delaware Denbighshire, WLS Derbyshire, ENG Devon, ENG District Of Columbia Dorset, ENG Dumfries and Galloway, SCT Dumfries-shire, SCT Dunbartonshire, SCT Dyfed, WLS East Lothian, SCT East Riding of Yorkshire, ENG East Sussex, ENG England Essex, ENG Federated States Of Micronesia Fife, SCT Flintshire, WLS Florida Georgia Glamorgan, WLS Gloucestershire, ENG Grampian, SCT Greater Manchester, ENG Guam Guernsey, CHI Gwent, WLS Gwynedd, WLS Hampshire, ENG Hawaii Hereford and Worcester, ENG Herefordshire, ENG Hertfordshire, ENG Highland, SCT Humberside, ENG Huntingdonshire, ENG Idaho Illinois Indiana Inverness-shire, SCT Iowa Ireland Isle of Man Isle of Wight, ENG Jersey, CHI Kansas Kent, ENG Kentucky Kincardineshire, SCT Kinross-shire, SCT Kirkcudbrightshire, SCT Lanarkshire, SCT Lancashire, ENG Leicestershire, ENG Lincolnshire, ENG London, ENG Lothian, SCT Louisiana Maine Manitoba Marshall Islands Maryland Massachusetts Merionethshire, WLS Merseyside, ENG Michigan Mid Glamorgan, WLS Middlesex, ENG Midlothian, SCT Minnesota Mississippi Missouri Monmouthshire, WLS Montana Montgomeryshire, WLS Morayshire, SCT Nairn, SCT Nebraska Nevada New Brunswick New Hampshire New Jersey New Mexico New South WLS New York Newfoundland/Labrador Norfolk, ENG North Carolina North Dakota North Riding of Yorkshire, ENG North Yorkshire, ENG Northamptonshire, ENG Northern Ireland Northern Mariana Islands Northern Territory Northumberland, ENG Northwest Territory Nottinghamshire, ENG Nova Scotia Nunavut Territory Ohio Oklahoma Ontario Oregon Orkney, SCT Oxfordshire, ENG Palau Peebles-shire, SCT Pembrokeshire, WLS Pennsylvania Perth, SCT Powys, WLS Prince Edward Island Puerto Rico Quebec Queensland Radnorshire, WLS Renfrewshire, SCT Rhode Island Ross and Cromarty, SCT Roxburghshire, SCT Rutland, ENG Sark, CHI Saskatchewan Scotland Selkirkshire, SCT Shetland, SCT Shropshire, ENG Somerset, ENG South Australia South Carolina South Dakota South Glamorgan, WLS South Yorkshire, ENG Staffordshire, ENG Stirlingshire, SCT Strathclyde, SCT Suffolk, ENG Surrey, ENG Sussex, ENG Sutherland, SCT Tasmania Tayside, SCT Tennessee Texas Tyne and Wear, ENG Utah Vermont Victoria Virgin Islands Virginia Wales Warwickshire, ENG Washington West Glamorgan, WLS West Lothian, SCT West Midlands, ENG West Riding of Yorkshire, ENG West Sussex, ENG West Virginia West Yorkshire, ENG Western Australia Western Isles, SCT Westmorland, ENG Wigtownshire, SCT Wiltshire, ENG Wisconsin Worcestershire, ENG Wyoming Yorkshire, ENG Yukon Territory Other:

Postal Code*:

Country:
Other Australia Canada New Zealand UK Ukraine United Arab Emirates United States United States Minor Outlying Islands Other:

E-mail*:

Day Phone*:

Evening Phone:

Hearing Aid Suitability

DiY hearing aids are suitable for most adults who suffer from diminished hearing due to environment or age. They are not suitable where disease, trauma and/or genetic malformation contribute to the loss of hearing, nor are they suitable for children. All of these cases should be taken to an Ear, Nose and Throat medical doctor (E.N.T., MD). In compliance with the FDA and State regulations as well as for your personal protection and answer either YES or NO to the list of physical conditions stated below:

Answers To The Following Questions Are Required To Purchase Aids

Please indicate whether or not you have experienced any of the issues listed

Please Answer YES or NO in the field provided

Do you have a visible congenital or traumatic deformity of the ear*:

Sudden or rapidly progressive hearing loss within the previous 90 days*:

Acute or chronic dizziness*:

Surgical or medical procedure(s) involving the ear*:

Visible evidence of cerumen accumulation or a foreign body in the ear*:

Pain or any discomfort in your ears*:

Stroke*:

Ringing or buzzing sounds in one or both ears*:

Have you been exposed to any loud noises*:

Have you recently had a cold or ear infection*:

Medical Waiver Statement - PLEASE TYPE YOUR NAME IN THE FIELD BELOW*

I have been advised by DiY Hearing on the date of this submission, that the Food and Drug Administration has determined that my best health interest would be served if I had a medical evaluation by a licensed physician ( preferably a physician who specializes in diseases of the ear ) before purchasing a hearing aid.

Online Purchase

Important notice to prospective wearers: This product is designed for adults and is not to be worn by individuals under the age of 18. A prospective wearer may purchase hearing aids with out a medical exam by submitting a medical waiver statement as presented and signed above. By purchasing hearing aids from Do-it-Yourself Hearing Aids you agree that you are the person that will be the end user and wearer. You also agree that the reason for purchasing hearing aids is because you were evaluated by a licensed specialist and have been recommended to wear hearing aids.

Note: Ordering a hearing instrument from this web site constitutes your acknowledgment and acceptance of this "Waiver to Medical Evaluation Requirements".

Terms And Conditions Of Providing Private Information

If you have answered YES to any of the conditions listed above, you may be required to provide our company with a medical recommendation form that has been signed by the examining physician within the last (6) months.

I have been advised by the hearing aid dispenser listed on my Medical Waiver form that the Food and Drug Administration has determined that my best health interest would be served if I had a medical evaluation by a licensed physician (preferably before purchasing a hearing aid). By clicking on the I AGREE check box below I acknowledge that I do not wish to have a medical evaluation before purchasing a hearing aid, that I understand and agree with the above statements, and that I am 18 years of age or older.

THIS NOTICE DESCRIBES HOW HEALTH INFORMATION ABOUT YOU (AS A CLIENT OF THIS COMPANY) MAY BE USED AND DISCLOSED, AND HOW YOU CAN GET ACCESS TO YOUR INDIVIDUALLY IDENTIFIABLE HEALTH INFORMATION.

Please review this notice carefully and review our privacy policies then proceed to by checking the "I AGREE" box below.

By providing your contact information in the form above and clicking the "I AGREE" check box below, you agree that you have read and agree with the Privacy Policy associated with this purchase.

CLIENT CONSENT FOR USE AND DISCLOSURE OF PROTECTED HEALTH INFORMATION AND CLIENT RIGHTS

I hereby give my consent for Do-it-Yourself Hearing Aids to use and disclose protected hearing health related information (PHI) about me in order to carry out treatment, payment and hearing healthcare procedures. (The Notice of Privacy Practices provides a more complete description of such uses and disclosures.) I have the right to review the Notice of Privacy Practices prior to signing this consent. This company reserves the right to revise its Notice of Privacy Practices at anytime. A revised Notice of Privacy Practices may be obtained by forwarding a written request to the Privacy Officer at D.i.Y. Hearing, 102 Northfield Drive East, Bainbridge, IN 46105. With this consent, this company may call my home or other alternative location and leave a message on voice mail or in person in reference to any items that assist the practice in carrying out the associated treatment, payment or procedures such as appointment reminders, insurance items and any calls pertaining to my hearing healthcare.

I may revoke my consent in writing except to the extent that the practice has already made disclosures in reliance upon my prior consent. If I do not sign this consent, or later revoke it, DiY Hearing may decline to do business with me.

Under HIPAA, an individual has the following rights with regard to his/her personal health information (PHI):

• The right to authorize the use and disclosure of PHI for certain non-TPO purposes and for psychotherapy notes.
• The right to receive a copy of the practice's Notice of Privacy Practices.
• The right to request restrictions on certain uses and disclosures of PHI.
• The right to request restrictions on how the practice communicates PHI to the patient.
• The right to inspect and copy PHI. The right to request an amendment of PHI.
• The right to an accounting of the disclosures of PHI made by the covered entity for purposes other than TPO and not pursuant to a valid authorization.
• The right to complain about alleged violations to the practice.

By providing your contact information in the form above and checking the "I AGREE" box below, you agree that you have read and understand all of the information, terms and conditions set forth above.