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  • C972 Hearing Loss Services Hearing Loss Authorization: Worker Details

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    Dawn Casuncad
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    This document is a request form for hearing loss services from an Alberta Workers' Compensation Board claimant. It includes fields for the claimant's name, claim number, address, and date of birth. It also includes fields for the clinic name, address, phone number, and contact doing the work. The form requests a description of the service or product needed and the reason for the request, and asks if it is covered by the WCB contract. It will be used to request and authorize hearing loss services for a WCB claimant.

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    C972

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    This document is a request form for hearing loss services from an Alberta Workers' Compensation Board claimant. It includes fields for the claimant's name, claim number, address, and date of birth. It also includes fields for the clinic name, address, phone number, and contact doing the work. The form requests a description of the service or product needed and the reason for the request, and asks if it is covered by the WCB contract. It will be used to request and authorize hearing loss services for a WCB claimant.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Flag for inappropriate content
    0 views1 page

    C972 Hearing Loss Services Hearing Loss Authorization: Worker Details

    Uploaded by

    Dawn Casuncad
    This document is a request form for hearing loss services from an Alberta Workers' Compensation Board claimant. It includes fields for the claimant's name, claim number, address, and date of birth. It also includes fields for the clinic name, address, phone number, and contact doing the work. The form requests a description of the service or product needed and the reason for the request, and asks if it is covered by the WCB contract. It will be used to request and authorize hearing loss services for a WCB claimant.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
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    C972

    HEARING LOSS SERVICES


    P.O. BOX 2415 HEARING LOSS AUTHORIZATION
    EDMONTON, AB T5J 2S5
    FAX: 780-427-5863
    1-800-661-1993

    WCB Claim Number


    WORKER DETAILS [Claim#]
    Surname First Name and Initial Date of Birth (yyyy/mm/dd)
    [Surname] [FirstName]
    Claimant Mailing Address:

    Clinic information
    Provider Name Billing Number Date (yyyy/mm/dd)

    Address Street City/Town Province Postal Code Telephone Number

    Audiologist / Registered Hearing Aid Practitioner Providing Service Clinic Email address Fax Number

    Request information
    Is the product/service you are requesting covered under the WCB - Alberta Hearing Yes No
    Loss contract terms?
    Request (required):
    Description of request

    Reason for request (required):


    Please describe reason/rationale for request

    Last supply date:

    C972 - REV APR 2023 DES: N/A

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