NIHL Trial Period Follow-Up Form

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Mail To:
200 Front Street West
Toronto ON M5V 3J1
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NIHL Trial Period
Follow-Up Form
OR Fax To:
416-344-4684
OR 1-888-313-7373
Claim Number (If known)
To avoid delays, please complete in full printing in black ink.
A. Patient & Employer Information Section (Patient to Complete this Section)
Last Name
start >
First Name
Init.
Address (no. street, apt.)
City/Town
Date of
Birth
dd
Prov.
mm
yy
Date of
Accident
mm
dd
yy
Date of
Assessment
If return to work is considered, has the employer been contacted?
mm
dd
Telephone No.
Postal Code
yy
Sex
M
yes
F
no
Employer Name
Supervisor/Contact Name
Address (no. street, apt.)
City/Town
Prov.
Telephone No.
Postal Code
B. Health Professional/Service Provider Billing Information
Health Professional/Service Provider Name (please print)
Service Code
Facility
Complete these fields if HST is applicable to this form
HST Registration No. Service Code HST Amount Billed
NIHLTPF
ONHST
Address (no. street, apt.)
$
.
WSIB Provider ID.
Your Invoice No.
City/Town
Prov. Postal Code
Telephone No.
Fax
Extension
C. Outcome Measurement (COSI™ - Client Oriented Scale of Improvement)
COSI™
yes
(please attach)
(please explain)
no
If no, explain
A.
B.
Degree of change
COSI™ column totals
Final ability
COSI™ column totals
Worse
No Difference
Slightly Better
Better
Much Better
=
Hardly Ever
Occasionally
Half of the Time
Most of the Time
Total #
Category Identified
A=B
Almost Always
=
LEFT SIDE
RIGHT SIDE
Manufacturer/Model
Manufacturer/Model
Serial Number
Serial Number
Style
Style
ITE
Comments:
2827A (06/10)
ITC
CIC
BTE
ITE
ITC
CIC
BTE
Comments:
Page 1
NIHL Trial Period
Follow-Up Form
Last Name
Claim Number (If known)
First Name
D. Verification
Hearing instrument is appropriate for patient's maximum loudness tolerance level and required gain for audiometric configuration
(frequency response):
Yes
No
Verification measures, labeled with respect to relative position of volume control, acoustic controls and stimulus input level are required.
Attached
Real-Ear Measurements
Sound Field Evaluation
Other
Care and maintenance of hearing instrument(s) and patient expectations from hearing instrument(s) have been addressed.
Yes
No
E. Signature of Health Professional/Service Provider
I,
the service provider, feel this hearing instrument fitting is
subjectively appropriate.
(Print Name)
Signature of Health Professional/Service Provider
Date
dd
mm
yy
Please print, sign and date this form before returning to the WSIB
F. Patient - Read Before Signing
I realize that I had up to 30 days to assess my hearing instrument(s). I now find that my hearing instrument(s) are beneficial to me and have decided to keep
them. I understand that my hearing instrument(s) will be replaced only if necessary (e.g. change in hearing status beyond the tolerance of this current hearing
instrument). If problems arise with my hearing instrument(s) I will return to the service provider in a timely manner.
Signature of WSIB Patient
dd
Date
mm
yy
Please print, sign and date this form before returning to the WSIB
2827A2
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