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Yukon WSCB Prior Approval Request, Hearing (F-0049)

Hearing service providers send this one-page request to the Yukon WSCB before supplying hearing aids or assistive listening devices on a hearing loss claim. It identifies the clinic, clinician and worker, notes whether the worker is a new or previous hearing aid user, lists invoice costs by ear, and must enclose an audiogram and a written report. A WSCB adjudicator approves or declines it.

Who completes it

The audiologist, or a hearing instrument practitioner under an audiologist's supervision, completes the clinic, worker, device and cost sections. The worker signs the cost-sharing section when the chosen devices cost more than WSCB will fund, and a WSCB adjudicator completes the approval box.

Submitting and payment

How to submit it
Fax or mail it to WSCB with the required audiogram and written report before supplying the device, using the contact details printed on the form.
Who pays
WSCB pays approved devices and services under its Schedule A fee structure for hearing claims, which caps device amounts and requires a copy of the manufacturer's invoice with billing.

Good to know

  • WSCB considers hearing aid replacement only once every four years unless needed earlier for electro-acoustic, medical, occupational or other acceptable reasons, and lost or stolen aids aren't replaced early.
  • When the worker chooses devices costing more than WSCB funds, the worker signs section E agreeing to pay the difference, and the form splits the WSCB and client amounts.
  • Noise-induced hearing loss claims need at least 25 dB loss in each ear, averaged at 500, 1000, 2000 and 3000 Hz, verified by an audiometric assessment.
  • After the device is supplied, bill on the Service provider report for hearing claims (F-0070); Schedule A accepts billing for up to one year after the service.

Get the official form

Download the current version from the source each time; forms change without notice.

Prior approval request hearing claims

Official pagePDF

Fill it with Vero

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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How this list is checked

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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Frequently asked questions

What must be enclosed with the Yukon hearing prior approval request?

An audiogram and a written report, both marked as required on the form. Under Schedule A, a full hearing assessment includes air and bone conduction testing, speech reception thresholds and discrimination scores, and tinnitus matching where applicable, with a written report to accompany the audiogram. Add comments and the invoice cost for each ear.

Which hearing devices need WSCB prior approval?

Under Schedule A, hearing aids, FM systems, amplified telephones and infrared TV systems all require prior approval, as does the fitting fee for assistive listening devices. Earmolds do not. Device amounts are capped, and the worker pays any difference above what WSCB funds after signing the cost-sharing section of this form.

How often will Yukon WSCB replace hearing aids?

Policy 2.6 says replacement requests are considered once every four years, unless replacement is needed earlier for electro-acoustic, medical, occupational or other acceptable reasons. Early replacement must be requested by the worker with objective evidence, and early replacement is not approved when hearing aids are lost or stolen.