Washington hearing aid and durable medical equipment providers use this one-page fax request to get Provider Hotline authorization on a workers' compensation claim. It covers DME, hearing aid repair or supply, and hearing aid replacement or supply. The provider lists the prescribing provider, billing codes, date of service, estimated total cost and, for hearing aids, each ear's serial number, the problem and the reason for repair.
The hearing aid, audiology or DME provider completes the business, worker and request sections. L&I completes the authorization response and returns it by fax.
Download the current version from the source each time; forms change without notice.
Hearing Aid Repair/Durable Medical Equipment Provider Hotline Service Authorization Request
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 and their requirements change without notice, so check the official page for the current version before you complete one.
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For a hearing aid more than 5 years old, attach a completed Hearing Services Worker Information form (F245-049-000) to this authorization request and check the replacement rules in L&I's Medical Aid Rules and Fee Schedules. List the serial number for each ear involved and the estimated total cost.
By fax. The response section is marked authorized, duplicate request, referred or missing information, with comments, and notes when the claim is self-insured so the request belongs with that employer.