Hearing Aid and Hearing Aid Repair Prior Approval Request Form

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PA#:
Date:

Section 1: Client Information

Client's Surname:
Date of Birth: (DD/MM/YY)
Given Name(s):
Sex: M | F
Band #:
Family #:
Client ID#:

Client Address:
Client Phone No.:

Section 2: Background Information (Please complete this section for new or replacement hearing aid requests)
Total Approved Costs:

• Date of most recent audiometric test (copy required for new or replacement hearing aids):
• Has the client ever worked in a noisy environment? Yes | No
  If yes, type of work and how long.
• Is the hearing loss the result of an injury? Yes | No
  If yes, please indicate when and where:
• Has the client ever applied with WCB? Yes | No ~
  If yes, please indicate claim number:
• Are any of these expenses covered under any other public or private health care plan: Yes | No

Section 3: Initial Benefit Requests, Replacements, and Repairs (for new or replacement hearing aids, a copy of the most recent audiometric test must be included for this section to be evaluated. Current hearing aid information must be included for repair and/or replacement requests).

• Benefit Code:
  Description of Benefit :
  Left Ear:
  Right Ear:
  Unit Cost:
  Manufacturer Name:
  Model No. or Name:
  Date of Fitting:
  Serial No.:
  
  Reason for request:

Section 4: Provider information

Provider Name:
Provider #:
Provider Address:
Telephone #:
Fax#:
I hereby certify that the above information is true and complete.
Provider Signature:
Date:

Secion 5: Decision