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WCB Alberta C662: Hearing Loss Assessment Form

Hearing loss service providers use this two-page form to record an assessment for a worker's WCB-Alberta hearing loss claim. It captures pure-tone and speech audiometry, tympanograms, acoustic reflexes and reflex decay, a background history covering noise exposure, tinnitus, ototoxic medications and family history, and the degree and type of loss with recommendations. The form says to complete all pages in full.

Who completes it

The audiologist or hearing aid practitioner who performs the assessment completes every page and signs with their credentials; the form also records who requested the booking.

Submitting and payment

How to submit it
Fax or mail the completed form to WCB-Alberta using the details printed on it, with the WCB claim number and your WCB billing number.
Who pays
WCB-Alberta pays the assessment under service code HL 01 for an initial assessment or HL 02 for a reassessment, with HL 01 AUD and HL 02 AUD used when an audiologist completes it.

Good to know

  • Degree of hearing loss is graded per ear from normal (0 to 15 dBHL) through minimal, mild, moderate, moderate-severe and severe to profound (91+ dBHL).
  • Recommendations include family physician or ENT referral, reassessment after medical treatment, hearing conservation measures, hearing aid repair or trial, and auditory brain response (ABR) testing.
  • The form records the date a noise-induced hearing loss package was given to the worker, plus any current hearing aid's style, make, model, serial number and purchase date.
  • Related WCB-Alberta forms include the hearing loss authorization (C972), hearing aid invoice (C659), purchase agreement (C1042) and hearing aid replacement requests (C1265 and C1265B).

Get the official form

Download the current version from the source each time; forms change without notice.

Hearing loss assessment - C662

Official pagePDF

Fill it with Vero

If your copy of the form is a fillable PDF, upload it once and Vero Documents fills it from the visit note and the chart, ready for you to review and sign. Download, print, or email the finished form, with the patient’s consent.

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How this list is checked

A form is listed only after its name and number were confirmed on the issuing agency’s or insurer’s own website, or in the form itself. Each entry links to that source. The list was last checked in October 2026. Forms change without notice, so download the current version from the official page before you fill it in.

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Frequently asked questions

Who can complete the WCB Alberta hearing loss assessment?

Hearing loss service providers, listed under hearing aid practitioners and audiologists on WCB-Alberta's forms page. The billing section separates initial and reassessment codes for audiologists (HL 01 AUD, HL 02 AUD) from the general codes (HL 01, HL 02), and the provider signs with their credentials.

What tests does form C662 record?

Pure-tone air and bone conduction thresholds from 125 to 8000 Hz for each ear, masked and unmasked; speech audiometry including speech reception threshold, word recognition and most comfortable and uncomfortable loudness levels; tympanometry with middle ear pressure, compliance and volume; ipsilateral and contralateral acoustic reflexes; and reflex decay at 500 and 1000 Hz.