Forms and publications for professionals
This page includes a range of forms and publications relating to Australian Government Hearing Services Program (the program) for professionals. Some forms also have a corresponding factsheet, please read the factsheet to ensure the form is filled out correctly.
To assist service providers with navigating the use of the new forms a Frequently Asked Questions page has been developed - FAQs - Provider Forms.
Forms
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 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 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 Word |
|
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 |
Word |
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. |
Commonwealth statutory declaration Word |
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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 Word |
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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. |
Request to Fit a Non-Scheduled Device Word |
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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 |
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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 |
Reason B - ECR 2 (speech discrimination) |
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 Word |
Publications
Eligibility Criteria for Refitting
Service providers should exercise their clinical judgment when making decisions about refitting. Service providers are required to fully document the reasons for refitting and retain this on the clients file. Frequently asked questions have been prepared to assist service providers on the Eligibility Criteria for Refitting.
Clients Rights and Responsibilities Poster
Hearing Service Providers are responsible for ensuring the Clients Rights and Responsibilities poster is displayed in the waiting area of each site.
If you do not wish to download and print the poster yourself, please use the online order form.
DVA Poster - Choosing your hearing device
The Department of Veterans' Affairs and the Department of Health developed a joint factsheet to help inform DVA client's about hearing devices available through the Hearing Services Program.
Contracted Service Provider Notices
This webpage lists all Contract Service Provider Notices.
Provider Factsheets
This webpage provides a link to all provider factsheets.
Contacting the Department of Health and Age Care and other Agencies