When the WSIB approves replacement hearing aids because of a new prescription after a patient's first year of bundled hearing services, this three-page report closes the mini bundle. It records the service and fitting dates, the patient's 15-item outcome questionnaire and the final device. The provider completes it with the patient at the end of the 30 to 90-day trial, once the final aid is chosen.
The hearing health care provider who did the initial assessment completes it with the patient and signs Section F. The patient completes the Section D questionnaire and signs the Section G declaration in person.
Download the current version from the source each time; forms change without notice.
Hearing services mini bundle outcome report
Miniforfait de services auditifs – Rapport des résultats
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When a patient is approved for replacement hearing aids due to a new prescription after completing their first year of bundled hearing services. The WSIB must pre-approve the replacement first. The provider then completes the report with the patient at the end of the 30 to 90-day trial, once the final aid is selected.
Audiologists bill BSHAMINL or BSHAMINR and hearing instrument specialists BSHHMINL or BSHHMINR, by ear, using the trial start date as the service date. The report itself is billed under BSHORMIN. The WSIB processes payment only after it receives both the completed report and the bill, and the patient must sign in person.
Yes. The WSIB publishes a French version, form 10692B, and the English form notes that it is available in French. Whichever version you use, the patient completes the outcome questionnaire within 30 to 90 days of fitting and signs in person before you submit it through wsib.ca/submit.