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WorkplaceNL HA-04 Hearing Aid Repair Request

When a worker's hearing aids need repair, the vendor sends WorkplaceNL this one-page request. It identifies the vendor and client, the make, model and serial number of the right and left aids, and the reason for repair: dead, distorted, internal feedback, noisy, cracked or other, with comments.

Who completes it

The hearing aid vendor completes and signs it with the date. The worker does not sign.

Submitting and payment

How to submit it
Fax or mail it to WorkplaceNL with an HA-01 Purchase Order Requisition, which states that repair requests must include a completed HA-04.
Who pays
WorkplaceNL publishes hearing aid repair pricing (February 1, 2025) for vendors, who submit invoices and view payment information through its supplier portal.

Good to know

  • List each aid needing repair separately for the right and left ear, with its make, model and serial number.
  • Tick all reasons that apply, and use the comments box to explain anything that falls under other.
  • If repair is no longer cost effective, WorkplaceNL's HA-05 replacement form lists that as a reason to replace, with the manufacturer's estimated repair cost.
  • The printed title is Request For Repair, and the current version is dated March 2017.

Get the official form

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

HA-04 Hearing Aid Repair Request

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.

Vero is not affiliated with, or endorsed by, the agencies and insurers listed here. Read our editorial policy.

Frequently asked questions

Do I need a purchase order for a WorkplaceNL hearing aid repair?

Yes. The HA-01 Purchase Order Requisition states that requests for repairs must include a completed Request for Repair form, HA-04. Send both to WorkplaceNL, listing the repair as a product or service with its price on the HA-01.

What happens when a hearing aid isn't worth repairing?

Use HA-05, Hearing Aid Replacement Information, instead. One of its reasons to replace is that repair is no longer cost effective, with the manufacturer's estimated cost of repair, and aids under five years old need WorkplaceNL authorization before new ones are dispensed.