WorkSafeBC uses this form to record a comprehensive audiological assessment, including audiometric testing and diagnostic findings for hearing loss or tinnitus, and relies on it for claims adjudication. It captures the date the worker last worked in hazardous noise, retirement date, current amplification and hearing protection, medical history, type and degree of hearing loss, and recommendations for amplification.
A registered audiologist must complete and sign the assessment, because WorkSafeBC uses it for claims adjudication; the clinic section records the date of service and date of report.
Download the current version from the source each time; forms change without notice.
Audiological Diagnostic Assessment (Form 51D4)
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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Only a registered audiologist. WorkSafeBC's form page says the assessment must be completed by a registered audiologist because it is used for claims adjudication. The audiologist signs the form, and the clinic section records the date of service, the date of report and the clinic's details.
WorkSafeBC must receive it within 5 business days after the evaluation is completed. Submit it with the applicable fee code through My Provider Services and attach the audiogram or upload it separately. Audiograms must be legible, and WorkSafeBC will not reimburse illegible or incomplete documentation.