TX HHS Form 3503. Hearing Evaluation and Fitting and Dispensing Report

The TX HHS Form 3503, Hearing Evaluation and Fitting and Dispensing Report, is a crucial document for audiologists and physicians to record the results of hearing evaluations and fitting and dispensing processes. This form helps solve the problem of accurately documenting patient hearing test results and ensuring that necessary information is captured for insurance claims or reimbursement purposes.

The report requires specific information, including the client's name, date of birth, and address, as well as details about the examination date, place, and ambient noise levels. Audiologists and physicians must also complete puretone audiometry tests using ANSI 2004 standards and record the results in decibels. Additionally, the form includes sections for fitting and dispensing results, speech audiometry, and a certification statement.

The TX HHS Form 3503 is typically used by audiologists and physicians to document hearing evaluations and fitting and dispensing processes for patients with hearing impairments. Key features of this form include the requirement for ambient noise level measurements and the use of ANSI 2004 standards for puretone audiometry tests. The form also includes a certification statement that must be signed by the fitter and dispenser, indicating that the information provided is true, accurate, and complete.

• This form is used to document hearing evaluations and fitting and dispensing processes for patients with hearing impairments.
• Ambient noise level measurements are required using ANSI 2004 standards.
• Puretone audiometry tests must be conducted using ANSI 2004 standards and results recorded in decibels.