Please complete this form for all hearing aid replacements, regardless of the age of the hearing aid. Submit this form and supporting documents before ordering new hearing aids. When completing the form, please be sure to:

1. Include the original fit date of the hearing aid. Provide serial numbers (SN) for both left and right hearing aids.
2. Select valid replacement criteria (e.g., excessive repairs, inappropriate style).
3. Clearly explain the clinical rationale for replacement.
4. Provide repair history and cost quotes if requesting early replacement.
5. Attach a recent audiogram (within 6 months).
6. Include real ear measurement (REM) tracings, if hearing aids are functioning.
7. Include the original fit date of the hearing aid (even if the serial numbers have changed due to repair).

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 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