Form C1265 - Hearing Loss Services Hearing Aid Replacement Information
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2C1265
HEARING LOSS SERVICES
P.O. BOX 2415
Hearing Aid Replacement Information
EDMONTON, AB T5J 2S5
FAX: (780) 427-5863
1-800-661-1993
WCB Claim Number
Personal Health Number
Date of Accident (yyyy/mm/dd)
Please print clearly or type.
Worker’s Surname
First Name
Initial
Date of Birth (yyyy/mm/dd)
Address Street
City/Town
Province
Postal Code
Telephone Number
(
)
Retired
If yes, when? (yyyy/mm/dd)
Yes
No
Clinic Information
Provider Name
Billing Number
Date (yyyy/mm/dd)
Address Street
City/Town
Province
Postal Code
Telephone Number
(
)
Audiologist / registered hearing aid Practitioner providing service
Fax Number
(
)
Description of current hearing aid(s)
A hearing aid is replaced only as required, regardless of its age; a rationale must be noted and supported with
documentation. Additionally, if the present hearing aid is less than five years old, prior authorization from the
WCB Hearing Loss Adjudicator is required before new hearing aid(s) may be dispensed.
Clinic Name
Date Fitted (yyyy/mm/dd)
Age of the hearing aid in years
Right Ear
Manufacture Model
Style
Serial Number
Clinic Name
Date Fitted (yyyy/mm/dd)
Age of the hearing aid in years
Left Ear
Manufacture Model
Style
Serial Number
Repair History
Rationale to replace hearing aids(s)
Please check appropriate boxes
L
R
Real ear measurements demonstrate that the hearing aid is no longer providing adequate gain for the worker
(supporting documents required)
Electroacoustic analysis demonstrates that the hearing aid is no longer providing adequate gain for the worker
(supporting documents required)
A change in hearing aid style is required due to a significant change in hearing (>20dB) at three or more frequencies
(500 – 4000Hz)
A change in hearing aid style is required due to a significant change in physical condition (i.e. Stroke)
A change in hearing aid style is required due to improper fit resulting in feedback
The manufacturer will not repair the hearing aid(s) (Supporting document required)
Excessive repair history (Three or more manufacture repairs after warranty to a single hearing aid). Please indicate cost of repair below
and provide details in the troubleshooting notes.
Cost of repairs in past year: $
and manufacturer’s quote for repairs $
THIS DOCUMENT MAY BE EXAMINED BY ANY PERSON WITH DIRECT INTEREST IN A CLAIM THAT IS UNDER REVIEW.
C – 1265 REV MAR 2017
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