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.

Forms

Form and purpose

Downloadable forms

Examples

Claim 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 fillable form

Word

Claim for Payment form

Claim for payment

Device Quote

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

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 form                                               

Word

Commonwealth statutory declaration form

 

N/A

Maintenance Agreement

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

Maintenance Agreement

Non-Schedule Device Request

This form is used when seeking approval for a device that is not listed on a Schedule of Approved Devices.

 

PDF Fillable

Request to Fit a Non-Scheduled Device                                                  

Word Form

Request to Fit a Non-Scheduled Device

N/A

Private Services and Devices Acknowledgement

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

Private Services and Devices Acknowledgement

Revalidated Service Request

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

 

PDF Fillable

Request a revalidated service                                                         

Word

Request a revalidated service

 

Coming Soon!

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

 

N/A

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

Hearing Service Providers are responsible for ensuring the Clients Rights and Responsibilities poster is displayed in the waiting area of each site.

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

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