Hearing assistive technologies (HAT) request form - Form 10584A - Hearing device pre-approval and replacement

Sep 21, 2026

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Hearing assistive technologies (HAT) request form for audiologists and hearing instrument specialists seeking WSIB pre-approval for initial purchases or for the subsequent repair, replacement, or authorization of items that can present auditory, visual, or tactile information for people with work-related hearing loss. Includes practitioner and patient details, product and pricing fields, clinical rationale sections, replacement criteria (warranty, testing, unrepairable), required supporting documentation, and declarations and signatures for electronic submission. Claim submission is via the WSIB website or mail.

LanguageEnglish

CategoryForms

FormatPDF

Pages3

Reading Time1 min

AccessFree to download

Hearing assistive technologies (HAT) request form

Hearing health care practitioner information

Patient information

Section A: Initial HAT request

Section B: HAT request for replacement and lost, stolen or damaged

Health care practitioner declaration and signature

Patient acknowledgement and signature

Hearing assistive technologies (HAT) request form For use by audiologists and hearing instrument specialists Complete this form when requesting pre-approval from the WSIB for the initial purchase of items that can present auditory, visual, or tactile information to people with work-related hearing loss (e.g. , telephone amplifiers, television specific devices, alerting systems, *FM systems (*submit audiologist authorization and current hearing assessment) and for the subsequent repair or replacement of HAT. The HAT categories of products and negotiated manufacturer pricing are available on the TELUS Health provider portal. For requests to replace non-functioning HAT(s), please include a manufacturer report and/or supporting documentation when submitting this form. For lost, stolen or damaged HAT(s), please make sure the patient has completed and submitted the Declaration of lost, stolen or damaged hearing devices form (10570A) for WSIB consideration of replacement. For more information related to hearing device benefits or when entitlement has been established for any work-related hearing loss, please refer to the Operational Policy Manual (OPM) document \#17-07-04, Hearing Devices. You can submit the completed form at [wsib.ca/submit](wsib.ca/submit). If you don’t have access to our website, you can also mail your completed form to us. 10584A (04/22) Page 1 of 3 Hearing assistive technologies (HAT) request form Claim number [Visit](Visit wsib.ca/submit)[ ](Visit wsib.ca/submit)[wsib.ca/submit](Visit wsib.ca/submit) to submit this form and supporting documents. This form is to be completed by audiologists and hearing instrument specialists. Please read the instructions page before completion. | Hearing health care practitioner information | | | | --- | --- | --- | | Clinic name | Clinic phone number | WSIB provider number | | Clinic address | | Phone number | | Hearing health care practitioner’s name | | Registration number | | Patient information | | | | --- | --- | --- | | Last name | First name | Date of birth (dd-mmm-yyyy) | | Home address | | Phone number | | Please indicate the type of request. | | | | | | | | | | --- | --- | --- | --- | --- | --- | --- | --- | --- | | Section A: Initial HAT request | | | | | | | | | | Please indicate the following information for the Initial requested HAT. | | | | | | | | | | Initial HAT | | | | Product description | Manufacturer | Model | Product code | Price | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | Please provide clinical rationale for initial request for HAT. | | | | | | | | | | Section B: HAT request for replacement and lost, stolen or damaged | | | | | | | | | | Please indicate the type of HAT request: | | | | | | | | | | Replacement Lost Stolen Damaged | | | | | | | | | | 1. | Yes | No | Has the WSIB previously replaced a HAT for the patient? If yes, please provide supporting documentation and product information on the current HAT model. | | | | | | | 2. | Yes | No | Is the HAT within the manufacturer’s warranty period? | | | | | | | 3. | Yes | No | Has the manufacturer tested the HAT? If yes, please provide supporting documentation. | | | | | | | 4. | Yes | No | Is the HAT unrepairable? If yes, please provide supporting documentation. | | | | | | | I have included the manufacturer invoice/repair quote and/or supporting documentation (i.e. , manufacturer invoices/repair quote report) . | | | | | | | | | Email [accessibility@wsib.on.ca](accessibility@wsib.on.ca) if you need a different format or accommodation. Disponible en franҫais. [wsib.ca](wsib.ca | Mail:)[ | Mail:](wsib.ca | Mail:) 200 Front Street West, Toronto, Ontario, M5V 3J1 | Toll free: 1-800-387-0750 | TTY: 1-800-387-0050 | Fax: 1-888-313-7373 10584A (04/22) Page 2 of 3 [wsib.ca](wsib.

FAQs

Who should complete this hearing assistive technologies (HAT) request form?

Audiologists and hearing instrument specialists complete the form when requesting WSIB pre-approval or when submitting replacement/repair documentation.

What information is required for an initial HAT request?

The form requests details for the initial HAT, including product description, manufacturer, model, product code, price, and a clinical rationale for the initial request.

What documentation is needed for replacement or lost, stolen, or damaged HATs?

Replacement requests require manufacturer invoice/repair quote and/or supporting documentation, plus answers to eligibility checks (e.g., prior WSIB replacement, warranty period, manufacturer testing, unrepairable status). Lost, stolen, or damaged requests require a full explanation of how the device was lost, stolen, or damaged, and reference to the required declaration form for WSIB consideration.

Sep 21, 2026

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