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ES MEDICAID SERVICES 471-000-3 Page 1 of 4 471-000-3 Instructions for Completing Form DM-5H, "Physician's Report on Hearing Loss" USE: Form DM-5H "Physician's Report on Hearing Loss" is required for authorization for hearing aid(s). The hearing aid specialist coordinates the completion of Form DM-5H. The form is completed by the Hearing Aid Specialist and the client's physician. COMPLETION: The following fields are completed by the Hearing Aid Specialist except for the Physician s Examinatio.

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