Hearing service providers use this one-page Yukon WSCB report to bill for services and products on a hearing loss claim. It lists each service by date and ear, from hearing assessments and hearing aid fittings to adjustments, repairs and ear impressions, plus products such as hearing aids, ear molds and FM systems. The fitting date it records becomes the anniversary date for future replacement.
The clinician, an audiologist or a hearing instrument practitioner under an audiologist's supervision, completes the whole report and signs a certification that the goods or services were provided to the worker named. Only the clinician signs it.
Download the current version from the source each time; forms change without notice.
Service provider report hearing claims
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.
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.
Vero is not affiliated with, or endorsed by, the agencies and insurers listed here. Read our editorial policy.
The form allows a full hearing assessment once every four years and a hearing re-assessment once a year. Under Schedule A, the full assessment is done by an audiologist and includes otoscopy, tympanometry, air and bone conduction testing and speech testing, with a written report to accompany the audiogram.
The form states that the date of fitting will be considered the anniversary date for replacement. WSCB policy 2.6 considers hearing aid replacement requests only once every four years, unless an earlier replacement is needed for electro-acoustic, medical, occupational or other acceptable reasons, so the fitting date starts that four-year count.
Attach the manufacturer's invoice for hearing aids and assistive listening devices, and a printout of verification measures when billing the hearing aid post-fitting follow-up. Schedule A also requires the manufacturer's invoice with each out-of-office repair. Then total the services and products, add any comments and sign the certification.