Further Information
Submitting your Form
Before you send us this form:
 have you provided all mandatory information
marked with an asterisk (*)?
If you would like to know more about the program
or would like assistance, please contact us:
 has your doctor completed it?
Website www.hearingservices.gov.au
Email:
hearing@health.gov.au
 have you signed it?
Phone:
1800 500 726
TTY:
1800 500 496
Post:
Office of Hearing Services
Department of Health
Mail Drop Point 113
GPO Box 9848
Canberra ACT 2601
Once we process your application we will send
information on the outcome and what you need
to do next. This may take up to four weeks.
Instead of completing this form you can
immediately check your eligibility and apply
online at www.hearingservices.gov.au
National Relay Service
If you are deaf or have a hearing or speech
impairment, you can contact us online through the
National Relay Service at
https://www.iprelay.com.au/call/ or call us on
1800 555 727.
ALTERNATE CONTACT
Do you have an alternate person you
would like us to contact?*
If ‘Yes’ please provide their details below
Given Name
Family Name
Daytime Contact Number
(
Yes
Relationship to you
)
ALTERNATE CONTACT DETAILS (if required)
Postal Address
Suburb
Alternate Contact Email
State
Postcode
No
Disability Employment Services (DES) Program
If you are participating in the Australian
Government DES program, you may be
automatically eligible to receive hearing services
through the program and you will not be required to
complete this form. Please contact your DES Case
Manager who will need to apply on your behalf.
AUSTRALIAN GOVERNMENT
Hearing Services Program
Providing access to hearing services for
eligible people.
To find out if you are eligible and apply
online, visit our website at:
www.hearingservices.gov.au
If you do not have access to the internet or
would like to apply by mail, please send your
completed form to:
National Disability Insurance Scheme (NDIS)
If you are a participant of the NDIS, your National
Disability Insurance Agency planner will need to
apply on your behalf. Please contact your planner
to discuss your hearing needs.
Applications
Office of Hearing Services
MDP 113, GPO Box 9848
Canberra ACT 2601
Other Services
If you do not meet the eligibility criteria in this form,
we may have other services that may interest you.
To find out more, please visit our website
www.hearingservices.gov.au or call 1800 500 726.
If you would like to contact us please email
hearing@health.gov.au or call us on
1800 500 726 or 1800 500 496 (TTY)
Australian Government Hearing Services Program - Application Form
ELIGIBILITY TYPE*
PRIVACY AND YOUR PERSONAL INFORMATION
Tick the relevant box that relates to your eligibility*:

(a) Centrelink Pensioner Concession Card

(b) Centrelink Sickness Allowance

(c) DVA Pensioner Concession Card

(d) DVA Gold Health Repatriation Card

(e) DVA White Health Repatriation Card (for hearing loss)

(f) Dependent of someone with one of the above concessions

(g) Current Serving Member of the Australian Defence Force
ELIGIBILITY & APPLICANT DETAILS*
The following details are needed so we can confirm your eligibility:
Eligibility Number* e.g. your CRN or DVA number
Your personal information is protected by law, including the
Privacy Act 1988, and is being collected by the Australian
Government Department of Health (the Department) for the
purposes of determining eligibility for and administering the
Hearing Services Program.
If you do not provide this information then the Department will not
be able to provide you with hearing services under the program.
You can get more information about the way in which the
Department will manage your personal information, including our
privacy policy at www.hearingservices.gov.au.
By signing this form you are consenting to and authorising the
Department to collect, store and disclose your information,
including personal information.
Signature*
Date*
/
Title
Given Name*
Middle Name
DETAILS OF MEDICAL PRACTITIONER*
Are there any contraindications for the fitting of a hearing
device*
YES
(May still be eligible for other services)
NO
Signature*
Provider Number*
Date*
/
Residential Address*
/
APPLICANT CORRESPONDENCE PREFERENCES
Send your program correspondence to:*
Suburb*
Date of Birth (dd/mm/yyyy)*
DEPENDENT CONCESSION CARD HOLDER DETAILS
If you ticked option ‘f’ in the eligibility type above, please provide
the following concession card holder details:
Eligibility Type
Eligibility Number
Family Name
Date of Birth (dd/mm/yyyy)
/
Me
Postcode*
or
My Alternate Contact
or
Both
Send information to me by*
Contact Phone 1
/
Given Name
State*
Gender*
(
/
( )
Contact Number*
/
Family Name *
/
Medical Practitioner (MP) Name *
)
Email (enter address below)
Contact Phone 2
(
Post
)
APPLICANT POSTAL ADDRESS (if different to your
Optional Information (used for planning purposes)
Are you a resident of an aged care facility?
Yes
residential address and you prefer to receive correspondence
by mail)
Are you of Aboriginal origin?
Yes
Postal Address
Are you of Torres Strait Islander origin?
Yes
Do you speak a language other than English at
home? If yes, please provide languages spoken.
Yes
Suburb
State
Postcode
Note: if you have asked that an alternate contact receive your
information, please complete the alternate contact details on the
back of this form.