Department of Labor and Industries PO Box 44291 Olympia WA 98504-4291
If my claim for occupational hearing loss is allowed and if my doctor prescribes hearing devices, the following rights and conditions apply when I obtain hearing aids: 1. I am free to choose where I will obtain my hearing aid(s), for example, I can go to an audiologist, physician, ARNP, or fitter and dispenser. I cannot be charged a fee by a hearing aid provider if I choose to obtain my hearing aids with a different provider. The physician, ARNP, audiologist, or fitter and dispenser must obtain authorization from the department before I receive hearing aid(s). If I accept a hearing aid before the department authorizes it, I am totally responsible for paying for my hearing aid(s) and all future batteries, supplies, and repairs. The department will not reimburse me for these costs. If I choose to purchase a different hearing aid than was recommended for my hearing loss and authorized by the department, I am totally responsible for paying for my hearing aid(s) and all future batteries, supplies, and repairs. The department will not reimburse me for these costs. I cannot pay the difference in cost to upgrade my hearing aid(s). If I do, #4 above applies. When my hearing aids are delivered, the physician, ARNP, audiologist, or fitter and dispenser will check the hearing aids, fit them to me, and teach me how to use and care for the hearing aids. A sound field measurement or probe microphone measurements will be done to test my hearing ability. I should have my hearing aids checked during the first month after delivery to make sure I am hearing as well as possible. Following the initial fitting, while learning to use my hearing aids, I can go back to the physician, ARNP, audiologist, or fitter and dispenser to adjust the fit and/or improve my ability to hear. I can return the hearing aid within the first 30 days if I am not satisfied with my ability to hear. I must notify the department in writing when I return the hearing aids for the department to consider a different kind of hearing aid.
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10. If I return a hearing aid, I can choose to continue working with the same dispenser, who may have other options to suggest, or choose to work with a different physician, ARNP, audiologist, or fitter and dispenser. 11. The physician, ARNP, audiologist, or fitter and dispenser must obtain authorization as needed and bill the department directly for all services. They cannot bill me the difference between what the department pays and their charges. 12. The department will pay for repairs and replacement due to normal wear and tear. Any other loss or damage is my responsibility. 13. Each hearing aid comes with a minimum of one-year manufacturer's warranty from the date I receive it. During that time, there are no costs for repairs; the department pays future repairs for normal use of my hearing aids. 14. The department cannot pay for hearing aids that are lost, stolen, or damaged by non-work related accidents. 15. The department pays for my hearing aid batteries, supplies, and parts, as needed, with normal use of my hearing aids. I have read this form and understand the information given.
Date Worker (Print your name) Signature
I explained the above information to this client
Date Company Name Provider Number Provider Signature
Provider (Print your name)
F245-049-000 hearing services worker info 5-04