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.

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

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

About this resource

Publication date:
Publication type:
Form
Language:
English

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