HEARING AID PERFORMANCE CHECK - RIGHT

GENERAL NOTES IF THE BENEFIT GRID SPECIFIES A SPECIALIST, ONLY THAT SPECIALIST IS ACCEPTED. SHOULD "MD" BE INDICATED, THE SERVICE MAY BE PRESCRIBED/RECOMMENDED BY A GENERAL PRACTITIONER OR ANY MEDICAL SPECIALIST. COMMAS APPEARING IN THE "PRESCRIBER REQUIRED" AND "RECOMMENDER REQUIRED" COLUMNS INDICATE OR, EG. "MD", "RN" MEANS "MD" OR "RN". PROVIDER MUST SUPPLY A COPY OF THE MANUFACTURER'S INVOICE. THE DOLLAR LIMIT AND/OR FEE ON THE BENEFIT GRID INCLUDES THE MARK-UP PRE-AUTHORIZATION NOT REQUIRED FOR REPLACEMENT ISSUE UNLESS OTHERWISE INDICATED. SPECIAL NOTES