Try for free

WorkplaceNL HA-05 Hearing Aid Replacement

Hearing aid vendors use this one-page form to ask WorkplaceNL to replace a worker's hearing aids. It describes the current aids for each ear, including manufacturer, model, serial number, date fitted and clinic, the repair history, the reasons to replace, an explanation and the proposed solution, with an office-use section for WorkplaceNL's decision.

Who completes it

The hearing aid vendor completes it, and WorkplaceNL's office-use section records recommendations, approval and a signature. The worker does not sign.

Submitting and payment

How to submit it
Fax or mail it to WorkplaceNL at the number and address printed on the form.
Who pays
If the current aid is five years old or more and is replaced, the Hearing Aid Provider Invoice must accompany the form for payment; aids under five years old need authorization first.

Good to know

  • If the current hearing aid is less than five years old, WorkplaceNL's Hearing Loss Claims Department must authorize replacement before new aids are dispensed.
  • Reasons to replace, by ear: inadequate gain, improper amplification, improper fit causing feedback, significant change in hearing, inappropriate style for dexterity or acoustic needs, or uneconomic repair.
  • When repair is no longer cost effective, enter the manufacturer's estimated cost of repair on the form.
  • The printed title is Hearing Aid Replacement Information, and the current version was revised in March 2017, like WorkplaceNL's other HA forms.

Get the official form

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

HA-05 Hearing Aid Replacement

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.

See how Vero Documents works

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

When does WorkplaceNL need to authorize a hearing aid replacement?

When the present hearing aid is less than five years old. In that case, authorization from WorkplaceNL's Hearing Loss Claims Department is required before new hearing aids may be dispensed. For older aids that are replaced, the Hearing Aid Provider Invoice must accompany the form for payment.

What reasons for replacement does WorkplaceNL accept on HA-05?

The form lists inadequate gain, improper amplification for the hearing loss, improper fit resulting in feedback, a significant change in hearing, a hearing aid style that no longer suits dexterity or acoustic needs, repair that is no longer cost effective, and other, each ticked for right or left.