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Click ‘Get Form’ to open the AHI PA breceipt formbai - America Hears in the editor.
Begin by filling out the 'Patient Information' section. Enter your name, address, city, zip code, and phone number accurately.
In the 'Instrument Order Information' section, specify whether you are ordering a left (LT) or right (RT) hearing aid. Fill in the serial numbers, manufacturer, style, and model description as required.
Indicate the condition of the hearing aid by selecting either 'New', 'Used', or 'Reconditioned'.
Complete the financial details including total cost, insurance credits/discounts, down payment, and balance due on delivery. Ensure all amounts are clearly stated.
Review any additional purchases and fees outlined in the disclosure agreement before finalizing your entries.
Finally, sign and date the document where indicated to acknowledge receipt and understanding of terms.

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