US Hearing Partners Disclosure Statement

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

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Disclosure of Financial Interest and Arrangements:


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.


Informed Consent to Financial Interest and Arrangements:


I, the undersigned patient:

  • understand and am aware that the financial interest and arrangements described above will result in a financial benefit to Physician if I choose to purchase or receive items or services from the Physician Affiliated Entity, Optio, PLLC, or Eyes & Ears, LLC;
  • consent to the receipt of the financial benefit by Physician if I choose to choose to purchase or receive items or services from the Physician Affiliated Entity, Optio, PLLC, or Eyes & Ears, LLC;
  • understand that I may ask Physician any questions I may have related to the financial interest and arrangements described in this document;
  • am aware that there are other service providers that provide items and services similar to those provided by the Physician Affiliated Entity, Optio, PLLC, and Eyes & Ears, LLC;
  • am aware of my right to utilize such other service providers at my sole and absolute discretion; and
  • am aware that even if I am identified as a potential candidate for a hearing aid through the hearing screening and Physician recommends that I seek further evaluation or services from the Physician Affiliated Entity, Optio, PLLC, Eyes & Ears, LLC, or any other service provider, I am not obligated to do so.
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