Audiologist's assessment report for an occupational hearing loss claim.
- Completed by
- Audiologist
- Issued by
- WorkplaceNL
- Format
- Language
- English
WorkplaceNL HA-01 Hearing Aid Purchase Order Request
Hearing aid vendors use this one-page purchase order requisition to ask WorkplaceNL to authorize hearing aid products or services for a worker with a hearing loss claim. It lists the vendor name and number, the client and claim number, and each product or service with its price, and the vendor signs it with the number of pages sent.
Who completes it
The hearing aid vendor, an audiologist or hearing instrument practitioner, completes and signs it. The worker does not sign.
Submitting and payment
- How to submit it
- Fax or mail it to WorkplaceNL at the number and address on the form; requests for repairs must include a completed Request for Repair (HA-04).
- Who pays
- Price products and services with WorkplaceNL's HA-07 Hearing Aid Device Fee Structure; vendors view purchase orders, submit invoices and see payment information through WorkplaceNL's supplier portal.
Good to know
- A worker's hearing loss claim starts with an assessment by a registered audiologist and the Audiologist's Report (Form AR) sent with the audiogram.
- WorkplaceNL publishes an approved hearing aid device list, the HA-07 fee structure for June 25, 2026 to June 24, 2027, and hearing aid repair pricing.
- The printed title is Purchase Order Requisition, and the current version was revised March 2017.
- Medical reports and denied transactions still go through WorkplaceNL's connect service, while purchase orders and invoices are handled in the supplier portal.
Get the official form
Download the current version from the source each time; forms change without notice.
HA-01 – Hearing Aid Purchase Order Request
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.
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
What is WorkplaceNL Form HA-01 used for?
It is the purchase order requisition a hearing aid vendor sends WorkplaceNL to request products or services for a client with a hearing loss claim. Each product or service is listed with its price, and repair requests must include the HA-04 Request for Repair.
How do hearing aid vendors see WorkplaceNL purchase orders?
WorkplaceNL says health care service providers and vendors view purchase orders, submit invoices and view payment information through its supplier portal. New vendors register by contacting WorkplaceNL and are asked for banking information so payments can be made by direct deposit.