Schedule D - Primary Level Authorization To Treat - Hearing Services
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1Health Care Services
Phone: (306) 787-4370
200 – 1881 Scarth Street
Toll-Free Phone: 1-800-667-7590
Regina, SK
Fax: (306) 787-4311
S4P 4L1
Toll-Free Fax: 1-888-844-7773
MCARE
Schedule “D”
Primary Level Authorization to Treat – Hearing Services
To:
Saskatchewan Workers’ Compensation Board
From:
________________________________________________________ (name of clinic)
_______________________________________________________ (address of clinic)
Telephone Number: __________________
Fax Number: _____________________
Worker name: ___________________________ Claim Number: _______________
Re:
Employer: ______________________________ PHN:__________________________
Funding for the following services is requested for the above client:
□ Repair of current aid: Estimated cost ______ (as per the WCB fee schedule)
□ Issuance of a hearing instrument: □ Entry level aid
□ Mid range aid*
□ Premium aid*
*Mid range or premium is □ worker choice
OR
□ care provider recommendation**
**Medical rationale if care provider recommended mid range or premium aid:
_______________________________________________________________________
_______________________________________________________________________
(NOTE: WCB/worker may request refund if post review does not support mid range or premium product.)
WCB/worker will be invoiced using the
□ Sask. Hearing Aid Plan fee schedule OR
□ WCB fee schedule***
***WCB fee schedule calculation: Manufacturer’s price of ______ plus 10% handling fee of
_______ plus shipping cost of _______ plus $525 for fitting and follow fees = _______
Portion of the above fee to be billed to WCB: _____ (not to exceed $1500).
Proposed fee to worker: ______ (only that portion of the fees that exceeds WCB ceiling of $1500)
_____________________
____________________
Care provider signature
Worker signature
WCB response:
□ Approved
□ Denied
Date: _________
Case Manager: _____________________ Telephone #: ____________
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