If you provide hearing evaluations for B.C. workers, complete and submit this form whenever:

• The worker initiates a complaint about a change in their hearing (a hearing re-evaluation is needed (fee code 19692))
• Submitting a requesting for replacement hearing aids (Form 51W6) 

Note: If submitting a request for replacement hearing aids, please ensure that the updated audiogram results are within 6 months of the assessment.

Most sections of this form may be completed digitally if you prefer; however, you will likely find it simplest to complete the audiogram by hand.

Upload the form

When you’re ready to submit the form, please ensure you’ve provided all the required information and then send it to us using the appropriate channel:

• If submitting a request for a hearing aid replacement, use the claims document uploader. 
• If submitting a request for a hearing re-evaluation, use My Provider Services (fee code 19692).