Audiologists and hearing instrument specialists use this three-page form to get WSIB pre-approval before dispensing hearing assistive technology, such as telephone amplifiers, television devices, alerting systems and FM systems, to a patient with work-related hearing loss. It covers the initial purchase and later repair or replacement. The WSIB's hearing services program asks for it after the hearing aid trial ends and an outcome report confirms the patient is satisfied.
The audiologist or hearing instrument specialist completes the practitioner, patient and request sections and signs the declaration. The patient signs an acknowledgement that their provider is seeking WSIB approval on their behalf.
Download the current version from the source each time; forms change without notice.
Hearing assistive technologies (HAT) request form
Formulaire de demande de technologies d'aide auditive
Upload the fillable PDF 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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The form describes HAT as items that present auditory, visual or tactile information to people with work-related hearing loss, with telephone amplifiers, television-specific devices, alerting systems and FM systems as examples. The WSIB's hearing device page adds that HATs link the wearer to the sound source and are allowed case by case.
The WSIB's hearing services program asks providers to submit it after the hearing aid trial period ends and an outcome report confirms the patient is satisfied. The trial runs at least 30 and at most 90 days after fitting. The WSIB must approve the request before you dispense the technology.
Section B covers replacement and lost, stolen or damaged HAT. You indicate whether the WSIB previously replaced a HAT for the patient, whether it is within the manufacturer's warranty, whether the manufacturer tested it and whether it is unrepairable, then list the current model, serial number and original dispense date and attach the manufacturer invoice or repair quote.