Hearing health care providers use this four-page form to ask the WSIB to approve replacement hearing aids within the five-year hearing aid cycle, replace lost, stolen or damaged aids, or fund a clinical exception level aid. It records the reason for the request by ear, the current and requested devices, and the clinical rationale. The WSIB must approve an exception-level aid before it is dispensed.
The audiologist or hearing instrument specialist completes the provider sections, and clinical exceptions and prescriptions need an audiologist and/or physician signature in Section E. The patient completes Section D on how they use their hearing aids and signs the Section F acknowledgement in person.
Download the current version from the source each time; forms change without notice.
Hearing aid replacement and/or clinical exception request form
Formulaire de demande de remplacement de prothèse auditive et(ou) d'exception clinique
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When there has been a change in hearing of at least 20 dB at three frequencies in the 500 to 3,000 Hz range, a medical change in the ability to operate the aids, fitting issues, a change in work duties and environment, bimodal use or other medical causes, or repeated manufacturer repairs that make the aids no longer viable.
The WSIB's guidelines describe people whose clinical needs are not met by entry or mid-level devices, such as severe to profound hearing loss of 70 dB or poorer, severe to profound single-sided deafness, bimodal users, or combined hearing and vision loss. Physical fit and changed work duties can also qualify. Pre-approval is required before purchase.
For a replacement or clinical exception, attach supporting medical documentation, the prescription and the Hearing assessment form (3275A); an exception request also needs the manufacturer invoice for the mid-level aid. For lost, stolen or damaged aids, include the manufacturer's invoice, repair estimate or confirmation the aid is damaged beyond repair. Audiogram reports must be within six months of the test.