*Indicates required field

Hearing services program provider registration

To deliver the hearing services program, you must register, identify what clinic you work at, if applicable, and agree to the provider statement below.

First name *

Please capitalize the first letter of your first name

Last name *

Please capitalize the first letter of your last name

I work *

Clinic name

if applicable

Profession *

License number

Please provide your license number if you’re an audiologist or physician

Registration number

Please provide your registration number if you’re a hearing instrument specialist

Address (street number, street name, suite/unit number)

City *

Postal code *

Phone number *

Email *

Language *

Enter all the languages you provide services in

Provider billing ID number (i.e., 100XXXXXX) *

Provider statement:

I confirm that I have the scope of practice, knowledge and skill to deliver the hearing services program.
I agree to read all program materials on the WSIB website and deliver all services in person to the patient. I will complete all forms and reports in accordance with submission timelines as per program requirements and submit them through the WSIB’s online services.
I agree to make sure the designated clinic area is safe, and appropriate for delivering care and implement appropriate accessibility measures as outlined by the AODA.
I provide consent for the WSIB to list my professional contact information on their hearing services program directory, acknowledging that the WSIB is not responsible for any consequences resulting from the use by third parties of this information.
I will use the WSIB online services via TELUS Health to electronically bill for services performed.
I agree to act in a respectful, courteous, and collaborative manner with the patient, the WSIB and other health professionals involved in the person’s care.
I understand that the WSIB will conduct quality assurance activities and I agree to participate in any related discussions.
I agree to update the WSIB if any of my registration information or qualifications change.

By checking this box, I am confirming and agreeing to the above provider statement. I understand that if I do not adhere to the above statement, it may result in my removal from delivering the hearing services program and its directory. *