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WorkplaceNL HA-02 Hearing Aid Fitting Report

After fitting a worker's hearing aids, the vendor completes this one-page report for WorkplaceNL. It records the audiological profile with date tested, tympanometry, pure tones, SRT and word recognition scores, the make, model, serial number, ear mold and battery for each ear, any cost share, and a checklist confirming the client was instructed and counselled.

Who completes it

The hearing aid vendor completes and signs it, and the client signs the form and, if applicable, the cost-share agreement.

Submitting and payment

How to submit it
Fax or mail it to WorkplaceNL at the number and address on the form, attaching REM results or an aided audiogram.
Who pays
WorkplaceNL pays its approved amount; if the client chooses a more expensive aid, the cost share splits the total between WorkplaceNL and the client, who pays the extra and any added accessories.

Good to know

  • Attach real ear measurement (REM) results or an aided audiogram as verification of the fitting.
  • The checklist covers expectations during adjustment, cleaning and care, battery use, wax guards, insertion and removal, volume, telecoil if applicable, the trial period and troubleshooting.
  • Record that the client was given a Dri-Aid kit, an initial pack of batteries, owner's manuals, cleaning tools and cases.
  • The current version is dated March 2017, and WorkplaceNL publishes its list of approved hearing aid devices for providers.

Get the official form

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

HA-02 – Hearing Aid Fitting Report

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

What if a worker wants a more expensive hearing aid than WorkplaceNL approves?

The cost share section covers it. The client signs that, because the aid costs more than WorkplaceNL approved, they alone are responsible for the additional cost and for the cost and maintenance of any extra accessories. The form records the WorkplaceNL amount, client amount and total.

What must be attached to the HA-02 fitting report?

Real ear measurement (REM) results or an aided audiogram, under the verification, education and counselling section. The audiological profile on the form itself records the test date, tympanometry, pure tones, speech reception thresholds and word recognition scores for each ear.