Forms and publications for professionals

Form and purpose

Downloadable forms

Example

Claim for Payment Form

This form is used for all claims for payment for program services. This form is mandatory for all claims and must be retained by the provider. A copy of the completed claim form must be placed on the client’s record.

PDF fillable

Claim for Payment

Word

Claim for Payment

Client Application Form

The client application form can be downloaded and provided to clients to complete. Service providers can use the client application form to apply for the client through the Hearing Services Online Portal.

PDF fillable

Client Application - electronic version

Client Application - paper version

Word

Client Application - paper version

Client Relocation Consent Form

This form is used when a client provides consent to relocate to you. Client consent should be obtained prior to linking them to you in the portal. Written consent should be obtained prior to providing services to a client.

PDF fillable

Client Relocation Consent

Word

Client Relocation Consent

Device Quote Form

This form is used when recommending a fully and/or partially subsidised device to a program client. This form can be adapted but must include the specified information. Please refer to the Device Quote factsheet for further information.

Word

Device Quote

Word

Device Quote Examples

Lost Device Statutory Declaration Form

The statutory declaration form must be used for all lost devices that will be replaced under the program. Alternatively, relevant state/territory statutory declaration forms are accepted.

PDF

Commonwealth statutory declaration

Word

Commonwealth statutory declaration

Maintenance Agreement Form

This form is used for program clients who wish to enter into a Maintenance Agreement. This form can be adapted but must include the specified information. Please refer to the Schedule of Service Item and Fees for further information about maintenance.

PDF fillable

Maintenance Agreement

Word

Maintenance Agreement

Non-Scheduled Device Request Form

This form is used when seeking approval for a device that is not listed on a Schedule of Approved Devices. Please note that devices fitted retrospectively will not be approved.

PDF 

Request to Fit a Non-Scheduled Device

Word

Request to Fit a Non-Scheduled Device

Private Services and Devices Acknowledgement Form

This form is used to record the client’s acknowledgement of private services. This form can be adapted but must include the specified information. A Private Services Factsheet is available

PDF fillable

Private Services and Devices Acknowledgement

Word

Private Services and Devices Acknowledgement

Revalidated Service Request Form

This form is used to request a revalidated service. Further information about revalidated services is available on the program website.

Word

Request for a revalidated service

Reason A

Reason B - ECR 1

Reason B - ECR 2

Reason B - ECR 2 (speech discrimination)

Reason B - ECR 3

Reason B - ECR 4

Reason B - ECR 5

Wishes and Needs Tool (WANT)

This form is used for clients who have a hearing loss below the Minimum Hearing Loss Threshold and who are considering a hearing device through the program. This form can be adapted but must include the specified information. No changes to the questions or ratings are allowed. WANT instructions are also available.

PDF fillable

WANT form for clients

Word

WANT form for clients