Prescription for Hearing Aid

This a practice form that can be provided to patients or forwarded to health plans when requested or required for prior authorization or payment. Please note that the ability to prescribe is dictated by your state hearing aid and/or audiology practice acts and regulations and not, solely, by the utilization of this form. Also, this is a generic prescription form; some states (such as Illinois) may have more specific requirements or language for the hearing aid prescription. Please contact ADA or your state audiology association if you are seeking a state specific form or document.