Hearing Loss (HL)
There are two sets of forms available, those for which we have samples, and those that are submitter supplied with no defined format.
| Click on a link for available sample | |
| ACC109 | Request Time Extension |
| ACC259 | Hearing Aid Battery Order Prescription Form |
| ACC610 | Accident Questionnaire - Claimant |
| ACC611 | Hearing Aid Trial Outcome Report - Vendor (Redacted Copy) |
| ACC612 | Audiometric Report for Hearing Loss - Vendor |
| ACC613 | Questionnaire - Extra Information - Claimant |
| ACC723 | Loss of Hearing specialist Otolaryngologist Report |
| ACC724 | Questionnaire - Claimant |
| ACC725 | Report for Employers |
| ACC6235 | Hearing Needs Assessment - Client Under 18 years |
| ACC6236 | Hearing Aid Trial Outcome Report - Client Under 18 years - Provider |
| ACC6237 | Quote for Hearing Aids - Provider |
| ACC6238 | Audiometric Report - Client Under 18 years - Provider |
| ACC6300 | Authority to Collect Medical and Other Records |
| MMEXSPECR |
Specialist / GP / Other Treatment Provider Notes (Redacted Copy) Set Observation Description to Additional Diagnosis |
| No link present means submitter format applies |
| Appointment Time: With [Provider] on [Date] @ [Time] |
| AUDTST - Hearing Test Results from [Provider] [Date] |
| ENTCOM - Further Comments from ENT |
| Email Verification |
| Insurance Form |
| Invoice - Manufacturers |
| Letter - from Advocate |
| Letter - from Client |
| Letter - from Provider |
| Medical Records / Notes - from Provider |
| Permission to Release to Triton Hearing |
Software Vendor Resources
Should you, as a software vendor, want to know more have a look at Resources for Software Vendors of Audiologists
Support
If you have any questions, or would like to know more, please feel free to contact us.