Your hearing screening is part of a screening program designed to improve hearing health. Better hearing is associated with lower rates of depression, dementia and fewer hospital visits.
DISCLOSURE OF AND INFORMED CONSENT TO FINANCIAL INTEREST AND ARRANGEMENTS – US HEARING PARTNERS OF SOUTHLAKE, LLC
Based on the results of your hearing screening, your Physician and/or other health care professionals working with your Physician may recommend you to seek a hearing test, hearing aid evaluation, fitting, and/or related services from US Hearing Partners of Southlake LLC, an entity directly or indirectly owned in part by Physician (the “Physician Affiliated Entity”), and its business affiliates.
The Physician Affiliated Entity has service and financial relationships with Optio, PLLC and Eyes & Ears, LLC. The Physician Affiliated Entity has entered into a professional services agreement with Optio, PLLC, under which professional individuals who are employed or contracted with Optio, PLLC are contracted to provide hearing aid fitting services to customers of the Physician Affiliated Entity. The Physician Affiliated Entity has also entered into a management agreement with Eyes & Ears, LLC, pursuant to which Eyes & Ears, LLC manages the day-to-day business operations of the Physician Affiliated Entity. Pursuant to these arrangements described above, in the event you purchase or receive items or services from the Physician Affiliated Entity, Optio, PLLC, or Eyes & Ears, LLC, Physician is likely to receive an indirect financial benefit.
I, the undersigned patient: