Australian Government - Department of Health - Office of Hearing Services
Hearing Services Program

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

Claim for Payment

Word

Claim for Payment

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

Word

Client Application

 

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

Device Quote

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 Items 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.

PDF fillable

Request for a revalidated service

Word

Request for a revalidated service

Request for a revalidated service

Reason A

Reason B - ECR 1

Reason B - ECR 2

Reason B - ECR 3

Reason B - ECR 4

Reason B - ECR 5

Reason B - ECR 6

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

 

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 other Agencies

Legislation and contracts

For professionals

FAQs - Provider Forms

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