National Hearing Care

Claims for Payment

OHS Claim For Payment Form

This is a triplicate form that can be used to hand write the claim forms when the computers are unavailable. There is usually some pads of these available in the clinics.

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Provider Name, Voucher Number and Client number must be entered on all claim forms.

All Assessments, Maintenance and Aid Adjustments to be entered in these fields.

Fitting Item, Review = Date of Service etc. entered in this field.

Device Code, date of fitting etc. to be entered here.

3FAHL entered which is obtained at the Assessment.

Balance of all 3 fields in bottom box.

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All boxes must be completed for any claim. The top box needs to reflect the $ box eg. yes $36.75 or no $NIL.

The clients name must be entered, client sign and dated. The signature date must not be before the date of service for any item. Total Cost of Program = Client fee for Maintenance and client fee for devices. Service Provider no:020103B ABN Number: 68200763765 All boxes must be completed for all claims Boxes always marked the same No=tax exempt, Yes= GST registered.

Consulting Audiologists name must be entered and signed and dated by said person. Date must be after client date and date of service.

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Assessment Item 600

Claim Item 600 This client has a New Voucher and has attended for an Assessment Appointment. The Date of Service is the Assessment Date and the client is not required to pay maintenance at the Assessment.

Sign all Claim Forms with a Blue Biro

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Assessment Item 800

Claim Item 800 This client has a Return Voucher and has attended for an Assessment Appointment. The Date of Service is the Assessment Date and the client is not required to pay maintenance at the Assessment.

Sign all Claim Forms with a Blue Biro

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Assessment 600 & 610

Claim Items 600 & 610 This client has a New Voucher and has attended for an Assessment Appointment. The Date of Service is the Assessment Date and the client is not required to pay maintenance at the Assessment. The Audiologist also performed extra service during to appointment to warrant the claiming of the 810 item which represents Audiological Case Management.

Sign all Claim Forms with a Blue Biro

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Assessment 800 & 810

Claim Items 800 & 810 This client has a Return Voucher and has attended for an Assessment Appointment. The Date of Service is the Assessment Date and the client is not required to pay maintenance at the Assessment. The Audiologist also performed extra service during to appointment to warrant the claiming of the 810 item which represents Audiological Case Management.

Sign all Claim Forms with a Blue Biro

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Fitting & Review 630

Claiming Item 630 This client has a new voucher and attended for a fitting and review appointment. The client has never been fitted before with hearing aids. The client was fitted with one hearing aid (device) and the date of service was the review date. The client has elected to pay extra money to Top Up their device and this is mentioned in the Cost to client section. The client has also paid the maintenance fee and the Total Cost to client totals the maintenance fee together with the client cost of the device.

Sign all Claim Forms with a Blue Biro

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Fitting & Review 630 & Maintenance Exempt Item 777

Claiming Items 630 & 777 This client has a new voucher and attended for a fitting and review appointment. The client has never been fitted before with hearing aids. The client was fitted with one hearing aid (device) and the date of service was the review date. The client has elected to pay extra money to Top Up their device and this is mentioned in the Cost to client section. The client would normally pay maintenance however as the client is DVA exempt (this would be stated on the voucher) the item 777 is also claimed.

Sign all Claim Forms with a Blue Biro

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Fitting and Review 640

Claim Item 640 This client has a new voucher and attended for a fitting and review appointment. The client has never been fitted before with hearing aids. The client was fitted with two hearing aids (devices) and the date of service was the review date. The client has also paid the maintenance fee and the Total Cost to client shows the maintenance fee only.

Sign all Claim Forms with a Blue Biro

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Fitting and Review 640 & 777

Claim Items 640 & 777 This client has a new voucher and attended for a fitting and review appointment. The client has never been fitted before with hearing aids. The client was fitted with two hearing aids (devices) and the date of service was the review date. The client has elected to pay extra money to Top Up their device and this is mentioned in the Cost to client section. The client would normally pay maintenance however as the client is DVA exempt (this would be stated on the voucher) the item 777 is also claimed.

Sign all Claim Forms with a Blue Biro

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Fitting and Review 650

Claim Item 650 This client has a new voucher and attended for a fitting and review appointment. The client has never been fitted before with hearing aids. The client was fitted with one hearing aid (device) and the date of service was the review date. The client has elected not to take up the maintenance agreement and therefore will purchase all batteries and pay for all service and repairs done to the device. The client may take up maintenance 12 months from the fitting date.

Sign all Claim Forms with a Blue Biro

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Fitting and Review 660

Claim Item 660 This client has a new voucher and attend for a fitting and review appointment. The client has never been fitted before with hearing aids. The client was fitted with one hearing aid (device) and the date of service was the review date. The client has elected not to take up the maintenance agreement and therefore will purchase all batteries and pay for all service and repairs done to the devices. The client may take up maintenance 12 months from the fitting date.

Sign all Claim Forms with a Blue Biro

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Fitting and Review 820

Claim Item 820 This client has a return voucher and has previously been fitted with hearing aid/s. The client is currently been fitted with one device. The client is already covered for maintenance and therefore not maintenance is required at this time.

Sign all Claim Forms with a Blue Biro

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Fitting and Review 830

Claim Item 830 This client has a return voucher and has previously been fitted with hearing aids. The client is currently been fitted with two new devices. The client is already covered for maintenance and therefore no maintenance is required at this time.

Sign all Claim Forms with a Blue Biro

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Fitting and Review 820 & 700

Item 820 & 700 This client has a return voucher and has previously been fitted with hearing aid/s. The client is currently been fitted with one device. The client has elected to pay extra money to Top Up their device and this is mentioned in the Cost to client section The client is due to pay maintenance again and therefore the claim of 700 is made and the client is required to pay the at this time. As the client has paid the maintenance fee the Total Cost to client totals the maintenance fee together with the client cost of the device.

Sign all Claim Forms with a Blue Biro

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Fitting and Review 830 & 710

Item 830 & 710 This client has a return voucher and has previously been fitted with hearing aids. The client is currently been fitted with two new devices. The client is due to renew their maintenance again and therefore the claim of 710 is made and the client is required to pay the at this time. As the client has paid the maintenance fee the Total Cost to client totals the maintenance fee together with the client cost of the device.

Sign all Claim Forms with a Blue Biro

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Fitting and Review 820, 700 & 777

Claim Items 820, 700 & 777 This client has a return voucher and has previously been fitted with hearing aid/s. The client is currently been fitted with one device. The client has elected to pay extra money to Top Up their device and this is mentioned in the Cost to client section The client is due to pay maintenance again and therefore the claim of 700 is made. However the client is DVA exempt (this would be stated on the voucher) and therefore the item 777 is also claimed. The Total Cost to client totals the maintenance fee together with the client cost of the device.

Sign all Claim Forms with a Blue Biro

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Fitting and Review 830, 710 & 777

Claim Items 830, 710 & 777 This client has a return voucher and has previously been fitted with hearing aid/s. The client is currently been fitted with one device. The client has elected to pay extra money to Top Up their device and this is mentioned in the Cost to client section The client is due to pay maintenance again and therefore the claim of 700 is made. However the client is DVA exempt (this would be stated on the voucher) and therefore the item 777 is also claimed. The Total Cost to client totals the maintenance fee together with the client cost of the device.

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Sign all Claim Forms with a Blue Biro

Fitting and Review 840

Claim Item 840 This client has previously been fitted with hearing aid/s during the last 5 years and has either lost one or has damaged one beyond repair. An OHS Statutory Declaration is required to be completed for file record. The client is currently being fitted with one device. A replacement fee of $30.00 is required to be paid by the client. The client is already covered for maintenance and therefore no maintenance fee is required.

Sign all Claim Forms with a Blue Biro

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Fitting and Review 850

Claim Item 850 This client has previously been fitted with hearing aid/s during the last 5 years and has had either lost both or both are damaged beyond repair. An OHS Statutory Declaration is required to be completed for file record. The client is being re-fitted with two devices. A replacement fee of $30.00 is required to be paid by the client. The client has elected to pay extra money to Top Up their device and this is mentioned in the Cost to client section. The client is already covered for maintenance and therefore no maintenance fee is required.

Sign all Claim Forms with a Blue Biro

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Maintenance Renewal 700

Claim Item 700 This client has previously been fitted with one hearing aid, the client maintenance is due to be renewed. This is due on the anniversary of the client fitting date.

Sign all Claim Forms with a Blue Biro

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Maintenance Renewal 710

Claim Item 710 This client has previously been fitted with two hearing aids, the client maintenance is due to be renewed. This is due on the anniversary of the client fitting date.

Sign all Claim Forms with a Blue Biro

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Maintenance Renewal Items 700 & 777

Claim Items 700 & 777 This client has previously been fitted with one hearing aid. The clients maintenance is due to be renewed however the as client is DVA exempt (this would be stated on the voucher) the item 777 is also claimed.

Sign all Claim Forms with a Blue Biro

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Maintenance Renewal Items 710 & 777

Claim Items 710 & 777 This client has previously been fitted with two hearing aids. The clients maintenance is due to be renewed however as the client is DVA exempt (this would be stated on the voucher) the item 777 is also claimed.

Sign all Claim Forms with a Blue Biro

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Relocating Maintenance 711

Claim Item 711 This client has relocated to NHC with a relocation letter from OHS. The client already has one hearing aid form another provider and is already covered for maintenance. Therefore item 711 is claimed to take over the maintenance agreement. The client is NOT required to pay the fee again for another 12 months from the date this claim is made.

Sign all Claim Forms with a Blue Biro

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Relocating Maintenance 722

Claim Item 722 This client has relocated to NHC with a relocation letter from OHS. The client already has two hearing aids form another provider and is already covered for maintenance. Therefore item 722 is claimed to take over the maintenance agreement. The client is NOT required to pay the fee again for another 12 months from the date this claim is made.

Sign all Claim Forms with a Blue Biro

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Fitting and Review 840 & 888

Claim Items 840 & 888 This client is an exempt client who has previously been fitted with hearing aid/s during the last 5 years and one has been either lost or damaged beyond repair. An OHS Statutory Declaration is required to be completed for file record. The client is currently been re-fitted with two devices. A replacement fee of $30.00 is required to be paid by the client.

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Sign all Claim Forms with a Blue Biro

Fitting and Review 850 & 888

Claim Items 850 & 888 This client is an exempt client who has previously been fitted with hearing aid/s during the last 5 years and both have either been lost or damaged beyond repair. An OHS Statutory Declaration is required to be completed for file record. The client is currently been re-fitted with two devices. A replacement fee of $30.00 is required to be paid by the client.

Sign all Claim Forms with a Blue Biro

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Aid Adjustment 930

Claim Item 930 The client attended for an Aid Adjustment appointment and currently has one hearing aid. An aid adjustment is where the client is experiencing less than optional satisfaction with their hearing aid and where it is more than 12 months from the date of initial fitting. This claim may be made every 24 months if necessary. A new voucher is not required.

Sign all Claim Forms with a Blue Biro

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Aid Adjustment 940

Claim Item 940 The client attended for an Aid Adjustment appointment and currently has two hearing aids. An aid adjustment is where the client is experiencing less than optional satisfaction with their hearing aid and where it is more than 12 months from the date of initial fitting. As the client has two aids, a binaural aid adjustment item is claimed, even if only one aid is adjusted. This claim may be made every 24 months if necessary. A new voucher is not required.

Sign all Claim Forms with a Blue Biro

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Fitting and Review 760

Claim Item 760 This client has a current voucher (either new or return) and has attended a fitting and review appointment. The client has previously been fitted with one device on the right ear and is now being fitted with a device for left ear. The client is still covered under a maintenance agreement with the right device and the new aid will join that agreement.

Sign all Claim Forms with a Blue Biro

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Fitting and Review 770

Claim Item 770 This client has a current voucher (either new or return) and has attended a fitting and review appointment. The client has previously been fitted with one device on the right ear and is now being fitted with a device for left ear. The client is does not wish to have the aid covered by maintenance

Sign all Claim Forms with a Blue Biro

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Privately purchased aids 790

Items 790 (for a monaural aid) and 791(for binaural aids) can be claimed for a client who has purchased their aid/s privately and then becomes eligible for the pension. The client requires an OHS Voucher and an assessment prior to this claim being made. The item should be claimed on the same claim form as the assessment.

The audiologist MUST find the aids to be in good working order. OHS expect the aids to last for at least two years. The client pays maintenance fee of $36.75. It is important to note the date of service for the 790/791 will become the fit date/s against the voucher thus making it fully serviced. If an Item 790 or 791 has been claimed previously and a refit is being contemplated a RETURN Voucher will be required together with the normal refit application to HO. Contracts will be either 820 or 830.

Sign all Claim Forms with a Blue Biro

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Privately purchased aids 791

Items 790 (for a monaural aid) and 791(for binaural aids) can be claimed for a client who has purchased their aid/s privately and then becomes eligible for the pension. The client requires an OHS Voucher and an assessment prior to this claim being made. The item should be claimed on the same claim form as the assessment.

The audiologist MUST find the aids to be in good working order. OHS expect the aids to last for at least two years. The client pays maintenance fee of $36.75. It is important to note the date of service for the 790/791 will become the fit date/s against the voucher thus making it fully serviced. If an Item 790 or 791 has been claimed previously and a refit is being contemplated a RETURN Voucher will be required together with the normal refit application to HO. Contracts will be either 820 or 830.

Sign all Claim Forms with a Blue Biro

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Provision of a Spare Aid 960

This item can be claimed for clients who have been fitted monaurally, have only one aidable ear and do not have access to their audiologist. The client would be disadvantaged if their aid was lost/damaged or needed to be sent away to be repaired. Approval must be obtained from OHS prior to fitting the aid. An item 630, 650 or 820 must have been previously lodged.

Sign all Claim Forms with a Blue Biro

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