Part A If you are an Australian citizen or by alendar


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									   Part A: If you are an Australian citizen or                                                                                           Return Client
                                                                                      Choice of Provider
  permanent resident 21 years or older and                                                                                               If the applicant HAS previously received a voucher from
                                                                  The Office of Hearing Services produces a Local
  you meet the following conditions you are                                                                                              the Office of Hearing Services, a Doctor OR a hearing
                                                                  Provider Directory to inform you about the providers of
   eligible for a hearing services Voucher.                                                                                              services provider can sign and complete this part.
                                                                  hearing services who are located closest to your home.
  If you have a Department of Veterans’ Affairs                   In addition, the Office can send you information about                 Return Client Number (if applicable)
  Repatriation Health Card or you are a dependant                 hearing service providers at other locations.
  of a person who has one of these cards:                         For example: an alternative address may be used if you:
       DVA Pensioner Concession Card                              • Regularly visit a family member away from your home             Details of Referrer
       White Health Repatriation Card (for hearing loss)                                                                            (Doctor/Hearing Services Provider)
                                                                  • Want to attend appointments in the Central Business
       Gold Health Repatriation Card
                                                                      District or in a larger country centre                        Title         Last Name
  Card Number
                                                                  • Travel regularly
                                                                  Preferred Alternative Provider Location                           First Names
                                    OR                            Suburb                                      Postcode
  If you have a Pensioner Concession Card or receive a
  Centrelink Sickness Allowance Benefit, or you are a                                                                               Postal Address
  dependant of a person who has one of these cards:              By signing this form I consent to the Office of Hearing
                                                                 Services storing the information provided on this form
  Card Number
                                                                 and disclosing information to Centrelink, the Department of
                                                                 Veterans’ Affairs and the Australian Defence Force (if
                                    OR                           appropriate) to confirm my eligibility for hearing services, and                                 State           Post Code
                                                                 for these Agencies to disclose information to the Office of        Telephone Number
  If you are a current Serving Member of the Australian
                                                                 Hearing Services in confirmation of my eligibility. I
  Defence Forces:                                                understand that the information provided on this form may be        (        )
  Service Number                                                 supplied to the Health Insurance Commission for the purpose        OHS/GP Practitioner number
                                                                 of payment to hearing services providers of service claims.
                                                                 I understand that my hearing services provider will
Title       Last Name                                            maintain records of my clinical needs and treatment and            After examining the applicant, I advise that there are:
                                                                 that these clinical records may be made available to the
                                                                                                                                            contraindications or limitations to the fitting of a
                                                                 Office of Hearing Services for audit and review purposes.
First Names                                          Sex (M/F)                                                                              hearing aid,
                                                                 Your signature
                                                                                                             Date                           no contraindications or limitations to the fitting of a
                                                                                                                  /      /                  hearing aid.
Date of birth           Telephone Number
        /      /        (       )                                                                                                   Signature of Referrer
                                                                                Part B: Referral Details
Postal Address                                                                                                                      By signing the form, the referring Doctor or hearing
                                                                         Your Doctor or hearing services provider
                                                                                                                                    services provider is stating that they consider that the
                                                                                  must complete this part.
                                                                                                                                    applicant’s hearing status and/or hearing aid fitting is in
                                                                    New Applicant
                                                                                                                                    need of assessment or review.
                                                                    If the applicant HAS NOT previously received a
                                                                    voucher from the Office of Hearing Services, a
                            State        Post Code                  Doctor must sign and complete this part.                                                                           /      /
           Part C: Additional Information                  Alternative contact
                                                           If you want to, you can give us the name and
  The following information is used for planning           telephone number of a family member, friend or
      and reporting purposes or to assist in               neighbour who does not live in your home who we
communicating with you. Your response is optional,         can talk to if we are unable to contact you at home.
    but your assistance would be appreciated.
Do you speak a language other than English at home?
   No, only English                                        Telephone number                                         The Commonwealth
   Yes, other (please specify)                              (     )                                               Hearing Services Program

Are you of Aboriginal or Torres Strait Islander origin?
   No                                                                  For more information contact:
   Yes, Aboriginal/Torres Strait Islander
                                                                      1800 500 726 or (TTY) 1800 500 496             Application
For Aged Care Home Residents                                             email:               for a Hearing
If you a resident of an Aged Care home, would you like a
notification about your Voucher to be sent to the home?
                                                            Or visit the Office of Hearing Services Website at:
                                                                                                                  Services Voucher
Aged Care Home
                                                                      Please post the completed form to:
(Address if different to above)                                               Mail Drop Point 48
                                                                          Office of Hearing Services
                                                                       Department of Health and Ageing
                                                                                GPO Box 9848                        Commonwealth Department of
                          State             Post Code                       CANBERRA ACT 2601                           Health and Ageing

                                                                                                                      Office of Hearing Services

                                                                                                                                                   2647 (0307)

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