During the 30 to 90-day trial of a patient's initial hearing aid, this two-page form tells the WSIB which aid was finally selected when it differs from the one first dispensed. It records the aid returned to the manufacturer for credit and the new aid chosen, with model, serial number, price and WSIB product code. A new form is completed each time the patient tries a different aid.
The assessing audiologist or hearing instrument specialist completes sections A to E and signs. The patient signs the Section F declaration in person, confirming they received the new hearing aid.
Download the current version from the source each time; forms change without notice.
Hearing aid selection change form
Formulaire de modification du choix de prothèse 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.
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.
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When the final hearing aid a patient selects during the 30 to 90-day trial differs from the aid first dispensed and billed. The WSIB's hearing services program asks for the form during the trial period, and for a new form each time the patient tries a different aid.
Yes, in person. The assessing hearing health care provider completes the form and must have it signed by the patient, who declares in Section F that they received the change in hearing aids described in Section D. The provider signs Section E.
Not for entry and mid-level aids. The WSIB's hearing services program says prior approval is no longer needed to trial different entry and mid-level aids during the trial period, and you report the final selection on this form. Exception-level aids still need WSIB approval before dispensing.