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 document used to record the results of hearing evaluations and fitting and dispensing processes for individuals. This form helps audiologists and physicians track patient information, test results, and fitting outcomes, ensuring accurate and complete records.

The form requires essential information such as client details (name, date of birth, address), examination dates, and puretone audiometry results. It also includes sections for ambient noise measurements, recorded threshold, and speech audiometry. The report must be completed by physicians or audiologists only, and the fitter and dispenser must sign below.

This form is typically used in clinical settings to document hearing evaluations and fitting processes for patients with hearing impairments. It is essential to ensure accurate and complete records, as this information may impact payment and satisfaction of claims from federal and state funds. The form's certification section emphasizes the importance of truthful reporting, underscoring the significance of this documentation.