8/2/2019 Sample Claim Forms
1/37
National Hearing Care
8/2/2019 Sample Claim Forms
2/37
This is a triplicate form that can be used to hand write the claim forms
when the computers are unavailable. There is usually some pads of theseavailable in the clinics.
OHS Claim For Payment Form
Notes:....
8/2/2019 Sample Claim Forms
3/37
Provider Name, Voucher Number and Client number must be entered on all claim forms.
All Assessments, Maintenance and Aid Adjustments to be entered in these fields.
Fitting Item, Review = Date of Service etc. entered in this field.
Device Code, date offitting etc. to be enteredhere.
3FAHL entered which is obtainedat the Assessment. Balance of all 3 fields in
bottom box.
Notes:
....
8/2/2019 Sample Claim Forms
4/37
The clients name must be entered, client sign and dated. The signature date must not be beforethe date of service for any item.
All boxes must be completed for any claim. The top box needs toreflect the $ box eg. yes $36.75 or no $NIL.
Boxes always marked the same
Total Cost of Program = Client fee forMaintenance and client fee for devices.
Service Provider no:020103B
ABN Number: 68200763765
No=tax exempt, Yes= GST registered.
Consulting Audiologists name must be entered and signed and dated by said person. Date mustbe after client date and date of service.
All boxes must be completed for all claims
Notes:....
8/2/2019 Sample Claim Forms
5/37
Claim Item 600
This client has a New Voucher and has attended for an Assessment Appointment.
The Date of Service is the Assessment Date and the client is not required to paymaintenance at the Assessment.
Assessment Item 600
Notes:...
Sign all Claim Forms with a Blue Biro
8/2/2019 Sample Claim Forms
6/37
Assessment Item 800
Claim Item 800
This client has a Return Voucher and has attended for an Assessment Appointment.
The Date of Service is the Assessment Date and the client is not required to paymaintenance at the Assessment.
Notes:...
Sign all Claim Forms with a Blue Biro
8/2/2019 Sample Claim Forms
7/37
Claim Items 600 & 610
This client has a New Voucher and has attended for an Assessment Appointment. TheDate of Service is the Assessment Date and the client is not required to pay maintenanceat the Assessment.The Audiologist also performed extra service during to appointment to warrant the claimingof the 810 item which represents Audiological Case Management.
Assessment 600 & 610
Notes:...
Sign all Claim Forms with a Blue Biro
8/2/2019 Sample Claim Forms
8/37
Assessment 800 & 810
Claim Items 800 & 810
This client has a Return Voucher and has attended for an Assessment Appointment.The Date of Service is the Assessment Date and the client is not required to paymaintenance at the Assessment.
The Audiologist also performed extra service during to appointment to warrant theclaiming of the 810 item which represents Audiological Case Management.
Notes:...
Sign all Claim Forms with a Blue Biro
8/2/2019 Sample Claim Forms
9/37
Claiming Item 630
This client has a new voucher and attended for a fitting and review appointment. Theclient has never been fitted before with hearing aids. The client was fitted with onehearing aid (device) and the date of service was the review date. The client has electedto pay extra money to Top Up their device and this is mentioned in the Cost to clientsection.
The client has also paid the maintenance fee and the Total Cost to client totals themaintenance fee together with the client cost of the device.
Fitting & Review 630
Notes:....
Sign all Claim Forms with a Blue Biro
8/2/2019 Sample Claim Forms
10/37
8/2/2019 Sample Claim Forms
11/37
Claim Item 640
This client has a new voucher and attended for a fitting and review appointment. Theclient has never been fitted before with hearing aids. The client was fitted with twohearing aids (devices) and the date of service was the review date.
The client has also paid the maintenance fee and the Total Cost to client shows themaintenance fee only.
Fitting and Review 640
Sign all Claim Forms with a Blue Biro
Notes:....
8/2/2019 Sample Claim Forms
12/37
Fitting and Review 640 & 777
Claim Items 640 & 777
This client has a new voucher and attended for a fitting and review appointment. Theclient has never been fitted before with hearing aids. The client was fitted with twohearing aids (devices) and the date of service was the review date. The client haselected to pay extra money to Top Up their device and this is mentioned in the Cost toclient section.
The client would normally pay maintenance however as the client is DVA exempt (thiswould be stated on the voucher) the item 777 is also claimed.
Sign all Claim Forms with a Blue Biro
Notes:....
8/2/2019 Sample Claim Forms
13/37
Claim Item 650
This client has a new voucher and attended for a fitting and review appointment. Theclient has never been fitted before with hearing aids. The client was fitted with one hearingaid (device) and the date of service was the review date.
The client has elected not to take up the maintenance agreement and therefore willpurchase all batteries and pay for all service and repairs done to the device. The clientmay take up maintenance 12 months from the fitting date.
Fitting and Review 650
Notes:....
Sign all Claim Forms with a Blue Biro
8/2/2019 Sample Claim Forms
14/37
Fitting and Review 660
Claim Item 660
This client has a new voucher and attend for a fitting and review appointment. Theclient has never been fitted before with hearing aids. The client was fitted with onehearing aid (device) and the date of service was the review date.
The client has elected not to take up the maintenance agreement and therefore willpurchase all batteries and pay for all service and repairs done to the devices. Theclient may take up maintenance 12 months from the fitting date.
Notes:....
Sign all Claim Forms with a Blue Biro
8/2/2019 Sample Claim Forms
15/37
Claim Item 820
This client has a return voucher and has previously been fitted with hearing aid/s. Theclient is currently been fitted with one device.
The client is already covered for maintenance and therefore not maintenance is requiredat this time.
Fitting and Review 820
Notes:....
Sign all Claim Forms with a Blue Biro
8/2/2019 Sample Claim Forms
16/37
Fitting and Review 830
Claim Item 830
This client has a return voucher and has previously been fitted with hearing aids.The client is currently been fitted with two new devices.
The client is already covered for maintenance and therefore no maintenance isrequired at this time.
Notes:....
Sign all Claim Forms with a Blue Biro
8/2/2019 Sample Claim Forms
17/37
Item 820 & 700
This client has a return voucher and has previously been fitted with hearing aid/s. Theclient is currently been fitted with one device. The client has elected to pay extra money toTop Up their device and this is mentioned in the Cost to client section
The client is due to pay maintenance again and therefore the claim of 700 is made and theclient is required to pay the at this time.
As the client has paid the maintenance fee the Total Cost to client totals the maintenancefee together with the client cost of the device.
Fitting and Review 820 & 700
Notes:....
Sign all Claim Forms with a Blue Biro
8/2/2019 Sample Claim Forms
18/37
Fitting and Review 830 & 710
Item 830 & 710
This client has a return voucher and has previously been fitted with hearing aids. Theclient is currently been fitted with two new devices.
The client is due to renew their maintenance again and therefore the claim of 710 ismade and the client is required to pay the at this time.
As the client has paid the maintenance fee the Total Cost to client totals themaintenance fee together with the client cost of the device.
Notes:....
Sign all Claim Forms with a Blue Biro
8/2/2019 Sample Claim Forms
19/37
Claim Items 820, 700 & 777
This client has a return voucher and has previously been fitted with hearing aid/s. Theclient is currently been fitted with one device. The client has elected to pay extra moneyto Top Up their device and this is mentioned in the Cost to client section
The client is due to pay maintenance again and therefore the claim of 700 is made.However the client is DVA exempt (this would be stated on the voucher) and thereforethe item 777 is also claimed.
The Total Cost to client totals the maintenance fee together with the client cost of thedevice.
Fitting and Review 820, 700 & 777
Notes:....
Sign all Claim Forms with a Blue Biro
8/2/2019 Sample Claim Forms
20/37
Claim Items 830, 710 & 777
This client has a return voucher and has previously been fitted with hearing aid/s. Theclient is currently been fitted with one device. The client has elected to pay extra moneyto Top Up their device and this is mentioned in the Cost to client section
The client is due to pay maintenance again and therefore the claim of 700 is made.However the client is DVA exempt (this would be stated on the voucher) and thereforethe item 777 is also claimed.
The Total Cost to client totals the maintenance fee together with the client cost of thedevice.
Fitting and Review 830, 710 & 777
Notes:....
Sign all Claim Forms with a Blue Biro
8/2/2019 Sample Claim Forms
21/37
Claim Item 840
This client has previously been fitted with hearing aid/s during the last 5 years and haseither lost one or has damaged one beyond repair. An OHS Statutory Declaration isrequired to be completed for file record. The client is currently being fitted with onedevice.
A replacement fee of $30.00 is required to be paid by the client.
The client is already covered for maintenance and therefore no maintenance fee isrequired.
Fitting and Review 840
Notes:....
Sign all Claim Forms with a Blue Biro
8/2/2019 Sample Claim Forms
22/37
Fitting and Review 850
Claim Item 850
This client has previously been fitted with hearing aid/s during the last 5 years and hashad either lost both or both are damaged beyond repair. An OHS Statutory Declarationis required to be completed for file record. The client is being re-fitted with two devices.
A replacement fee of $30.00 is required to be paid by the client.
The client has elected to pay extra money to Top Up their device and this is mentionedin the Cost to client section. The client is already covered for maintenance andtherefore no maintenance fee is required.
Notes:....
Sign all Claim Forms with a Blue Biro
8/2/2019 Sample Claim Forms
23/37
Maintenance Renewal 700
Claim Item 700
This client has previously been fitted with one hearing aid, the clientmaintenance is due to be renewed. This is due on the anniversary of the clientfitting date.
Notes:....
Sign all Claim Forms with a Blue Biro
8/2/2019 Sample Claim Forms
24/37
Claim Item 710
This client has previously been fitted with two hearing aids, the client maintenance isdue to be renewed. This is due on the anniversary of the client fitting date.
Maintenance Renewal 710
Notes:....
Sign all Claim Forms with a Blue Biro
8/2/2019 Sample Claim Forms
25/37
Maintenance Renewal Items 700 & 777
Claim Items 700 & 777
This client has previously been fitted with one hearing aid. The clients maintenance isdue to be renewed however the as client is DVA exempt (this would be stated on thevoucher) the item 777 is also claimed.
Notes:....
Sign all Claim Forms with a Blue Biro
8/2/2019 Sample Claim Forms
26/37
Claim Items 710 & 777
This client has previously been fitted with two hearing aids. The clients maintenance isdue to be renewed however as the client is DVA exempt (this would be stated on thevoucher) the item 777 is also claimed.
Maintenance Renewal Items 710 & 777
Notes:....
Sign all Claim Forms with a Blue Biro
8/2/2019 Sample Claim Forms
27/37
Claim Item 711
This client has relocated to NHC with a relocation letter from OHS. The client already hasone hearing aid form another provider and is already covered for maintenance. Thereforeitem 711 is claimed to take over the maintenance agreement. The client is NOT requiredto pay the fee again for another 12 months from the date this claim is made.
Relocating Maintenance 711
Notes:....
Sign all Claim Forms with a Blue Biro
8/2/2019 Sample Claim Forms
28/37
Relocating Maintenance 722
Claim Item 722
This client has relocated to NHC with a relocation letter from OHS. The client alreadyhas two hearing aids form another provider and is already covered for maintenance.Therefore item 722 is claimed to take over the maintenance agreement. The client isNOT required to pay the fee again for another 12 months from the date this claim ismade.
Notes:....
Sign all Claim Forms with a Blue Biro
8/2/2019 Sample Claim Forms
29/37
Fitting and Review 840 & 888
Claim Items 840 & 888
This client is an exempt client who has previously been fitted with hearing aid/s duringthe last 5 years and one has been either lost or damaged beyond repair. An OHSStatutory Declaration is required to be completed for file record. The client is currentlybeen re-fitted with two devices.
A replacement fee of $30.00 is required to be paid by the client.
Notes:....
Sign all Claim Forms with a Blue Biro
8/2/2019 Sample Claim Forms
30/37
Claim Items 850 & 888
This client is an exempt client who has previously been fitted with hearing aid/s during
the last 5 years and both have either been lost or damaged beyond repair. An OHSStatutory Declaration is required to be completed for file record. The client is currentlybeen re-fitted with two devices.
A replacement fee of $30.00 is required to be paid by the client.
Fitting and Review 850 & 888
Notes:....
Sign all Claim Forms with a Blue Biro
8/2/2019 Sample Claim Forms
31/37
Claim Item 930
The client attended for an Aid Adjustment appointment and currently has one hearing aid.An aid adjustment is where the client is experiencing less than optional satisfaction withtheir hearing aid and where it is more than 12 months from the date of initial fitting.
This claim may be made every 24 months if necessary. A new voucher is not required.
Aid Adjustment 930
Notes:....
Sign all Claim Forms with a Blue Biro
8/2/2019 Sample Claim Forms
32/37
Aid Adjustment 940Claim Item 940
The client attended for an Aid Adjustment appointment and currently has two hearing
aids. An aid adjustment is where the client is experiencing less than optionalsatisfaction with their hearing aid and where it is more than 12 months from the date ofinitial fitting. As the client has two aids, a binaural aid adjustment item is claimed, evenif only one aid is adjusted.
This claim may be made every 24 months if necessary. A new voucher is not required.
Notes:
....
Sign all Claim Forms with a Blue Biro
8/2/2019 Sample Claim Forms
33/37
Claim Item 760
This client has a current voucher (either new or return) and has attended a fitting andreview appointment. The client has previously been fitted with one device on the right earand is now being fitted with a device for left ear.
The client is still covered under a maintenance agreement with the right device and thenew aid will join that agreement.
Fitting and Review 760
Notes:....
Sign all Claim Forms with a Blue Biro
8/2/2019 Sample Claim Forms
34/37
Fitting and Review 770
Claim Item 770
This client has a current voucher (either new or return) and has attended a fitting andreview appointment. The client has previously been fitted with one device on the right earand is now being fitted with a device for left ear.
The client is does not wish to have the aid covered by maintenance
Notes:....
Sign all Claim Forms with a Blue Biro
8/2/2019 Sample Claim Forms
35/37
Privately purchased aids 790
Items 790 (for a monaural aid) and 791(for binaural aids) can be claimed for a clientwho has purchased their aid/s privately and then becomes eligible for the pension.
The client requires an OHS Voucher and an assessment prior to this claim beingmade. The item should be claimed on the same claim form as the assessment.
The audiologist MUSTfind the aids to be in goodworking order. OHSexpect the aids to last forat least two years. Theclient pays maintenance
fee of $36.75.It is important to notethe date of service forthe 790/791 will becomethe fit date/s against thevoucher thus making itfully serviced.
If an Item 790 or 791 has
Sign all Claim Forms with a Blue Biro
Notes:....
and a refit is being
contemplated a RETURNVoucher will be requiredtogether with the normalrefit application to HO.Contracts will be either 820or 830.
8/2/2019 Sample Claim Forms
36/37
Privately purchased aids 791
Items 790 (for a monaural aid) and 791(for binaural aids) can be claimed for a client
who has purchased their aid/s privately and then becomes eligible for the pension.The client requires an OHS Voucher and an assessment prior to this claim beingmade. The item should be claimed on the same claim form as the assessment.
The audiologist MUST find theaids to be in good working order.OHS expect the aids to last for atleast two years. The client paysmaintenance fee of $36.75.
It is important to note the dateof service for the 790/791 willbecome the fit date/s againstthe voucher thus making itfully serviced.
If an Item 790 or 791 has beenclaimed previously and a refit isbein contemplated a RETURN
Sign all Claim Forms with a Blue Biro
Notes:....
Voucher will be required together
with the normal refit application toHO. Contracts will be either 820or 830.
8/2/2019 Sample Claim Forms
37/37
Provision of a Spare Aid 960
This item can be claimed for clients who have been fitted monaurally, have only
one aidable ear and do not have access to their audiologist. The client would bedisadvantaged if their aid was lost/damaged or needed to be sent away to berepaired. Approval must be obtained from OHS prior to fitting the aid. An item630, 650 or 820 must have been previously lodged.
Sign all Claim Forms with a Blue BiroNotes:....
Top Related