Complete this form when requesting a replacement for lost or damaged hearing aids that are beyond normal wear and tear scenarios, regardless of the age of the hearing aid. When completing the form, please be sure to:

1. Include a signed letter from the worker explaining the loss or damage.
2. Provide the original serial numbers of the lost or damaged hearing aids.
3. Include the original fit date of the lost or damaged hearing aids (even if the serial numbers have changed due to repair).
4. Wait for written authorization before ordering or fitting new hearing aids.
5. Submit updated REMS (Form 83D72) and Serial Number Record (Form 69D9) after fitting new hearing aids.
6. Use the correct fee codes for invoicing after you receive approval from us.

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.

For more information

See the following sections in our Hearing Aid Provider Reference Manual for more information on:

• Hearing aid replacement requests and steps for fitting – Section 4.0
• Exchanged or returned hearing aids during the trial period – Section 5.0
• Cost share arrangement – Section 6.0
• Hearing aid replacement requests for aid(s) that have been lost or damaged beyond normal wear and tear – Section 7.0
• Accessories and optional upgrades – Section 9.0