Mail to: Department of Labor and Industries PO Box 44291 Olympia WA 98504-4291 Fax: 360-902-6252 Claim number: __________________________ Hearing Services Worker Information If my for occupation hearing loss is allowed and if my doctor prescribes hearing devices, the following rights and conditions apply when I obtain hearing aids: 1. I am free to choose where I will obtain my hearing aid(s). For example, I can go to a physician, ARNP, audiologist, or fitter and dispenser. I can't be charged a fee by a hearing aid provider if I choose to obtain my hearing aid(s) with a different provider. 2. The provider must obtain authorization from L&I before I receive hearing aid(s). 3. If I accept a hearing aid before L&I authorizes it, I am totally responsible for paying for my hearing aid(s) and all future batteries, supplies, and repairs. L&I will not reimburse me for these costs. 4. If I choose to purchase a different hearing aid than was recommend for my hearing loss and authorized by L&I, I am totally responsible for paying for my hearing aid(s) and all future batteries, supplies, and repairs. L&I will not reimburse for these costs. 5. I can't pay the difference in cost to upgrade my hearing aid(s). If I do, I am totally responsible for all future batteries, supplies, and repairs. L&I will not reimbursement for these costs. 6. When my hearing aid(s) are delivered, the provider will check the hearing aid(s), fit them to me, and teach me how to use and care for the hearing aid(s). A sound field measurement or probe microphone measurements will be done to test my hearing ability. 7. I should have my hearing aid(s) checked during the first month after delivery to make sure I am hearing as well as possible. 8. Following the initial fitting, while learning to use my hearing aid(s), I can go back to the provider to adjust the fit and/or improve my ability to hear. 9. I can return my hearing aid(s) with the first 30 days if I am not satisfied with my ability to hear. I must notify L&I in writing when I return the hearing aid(s) for consideration for a different kind of hearing aid. 10. If I return a hearing aid, I can choose to continue working with the same dispenser, who may have other options to suggest, or choose to work with a different provider. 11. The provider must obtain authorization as needed and bill L&I directly for all services. They can't bill the difference between L&I pays and their charges. 12. L&I will pay for repairs and replacement due to normal wear and tear. Any other loss or damage is my responsibility. 13. Each hearing aid comes with a minimum of one-year manufacturer's warranty from the date I receive it. During that time, there are no costs for repair. L&I pays for future repairs for normal use of my hearing aid(s). 14. L&I can't pay for hearing aid(s) that are lost, stolen, or damaged by non-work related accidents. 15. L&I pays for my hearing aid batteries, supplies, and parts as needed, with normal use of my hearing aid(s). Worker Signature: I have read this form and understand the information given. Print name Signature Date Provider Signature: I have explained the information above to this worker. Print name Signature L&I Provider Number American LegalNet, Inc. www.FormsWorkFlow.com F245-049-000 Hearing Aid Services Worker Information 04-2014