Complete or update this form each time a worker is provided with a new hearing aid or the hearing aid serial number changes due to a manufacturer repair. If a hearing aid is returned or exchanged during the 60-day trial period, a Hearing Aid Returns (Form 83D425) must be submitted along with this form.

Upload the form

When you’re ready to submit the form, please ensure you’ve provided all of the required information and then send it to us using our claims document uploader.