Hearing Services Program revalidated service request examples

These examples provide guidance to Hearing Services Program providers on how to correctly complete request forms for revalidated services.

Downloads

Example – Reason A

Example – Reason B – ECR 1

Example – Reason B – ECR 2

Example – Reason B – ECR 2 (speech discrimination)

Example – Reason B – ECR 3

Example – Reason B – ECR 4

Example – Reason B – ECR 5

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Publication date:
Date last updated:
Publication type:
Form
Audience:
Health sector
Language:
English
Description:

The example completed forms cover 7 different scenarios:

  • 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

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