Date

Patient Last Name First Name Last 4 Digits of SSN

Government BTE Order FormContract Period: May 1, 2021-October 31, 2021

Date

Patient Last Name First Name Last 4 Digits of SSN

Government BTE Order FormContract Period: May 1, 2021-October 31, 2021

______ ______

BEHIND-THE-EAR WIRELESS BEHIND-THE-EAR MODELS STANDARD COLORS WIRELESS ACCESSORIES

L

LL

L

R Livio Edge AI BTE R L

L

R Muse iQ i2400 Power Plus LLLLLLL

R Champagne (Default) SHT TV Streamer1 (43005-610) SurfLink Advanced Remote (130/70) BTE 13 (140/80) (60111-002)SHT Remote Mic Plus1R Sterling

(43006-610)R Livio BTE R (130/70) R Muse iQ Power Plus BTE SurfLink Basic Remote R Bronze 13 CROS Transmitter (60111-000)R Livio Edge AI BTE 13 SHT Mini Remote Mic1

R Espresso (43023-610)(130/70) SurfLink Remote Microphone 2 1 Livio Edge AI and Livio only (64067-000)R Slate SHT Remote Control1R Livio Edge AI BTE 13 2SurfLink Mini Mobile Adapter is only compatible

(43011-002)CROS Transmitter with the Surflink Remote Microphone 2 SurfLink Mini Mobile Adapter2R Black 3 Includes SurfLink Remote Microphone 2 and (64368-000)

Table Microphone1 (43044-600)SurfLink Mini Mobile Adapter R White with Sterling SurfLink Mini Mobile System3

SurfLink Media 2 (64155-000) (64067-200)

EARMOLDS EARMOLD STYLES MATERIAL COLOR VENT MODIFICATIONS

LL

LL

R Clear LLLLLL

R Hollow Canal Lock4 LLL

R Lucite LL

LL

R Tan8 LLLL

LLL

R As Large as Possible LLLLLL

R Bell Canal R Pink/Flesh R Light Brown/ R Canal5 R Silicone R Select-a-Vent - 3.37 mm R Canal Length: Short

Transparent Transparent R Half Shell5 R Silicone R Large Vent - 2.55 mm R Canal Length: MediumR Red7 R Medium Brown Printed R Skeleton5 R Standard/Medium Vent - R Canal Length: LongTube6 R Blue7 R Dark Brown 1.8 mm R Shell5 R Removal String

R Small Vent - 1.2 mm R Canal Lock5 R Surface Nanoshield R Pressure Vent - 0.8 mm Coating4 Hollow molds only available in Lucite 7 Not available in Silicone Printed Tubing

5 Available in Silicone Printed Tube 8 Only available in Lucite R No Vent 6 Only available in 13 Extra Heavy Tubing

STANDARD TUBING COLOR TUBING THIN TUBING DOMES

LLLLLLL

R 12 Standard LLLLL

R Clear (Default) L: 1 R: 1 L R Open 2 2

L R Occluded R 13 Standard (Default) R Red9

3 10 L:10R 13 Heavy R Blue9 4mm (sleeve)

4mm (sleeve)

5mm

5mm

6mm

6mm

7mm

7mm

9mm

9mm

11mm

11mm

3 R 13 Extra Heavy R Brown9

3+ 3+

4 4

4+ 4+

5 5

5+ 5+

R: R SnapConnect 13 Regular R Rose Transparent10

L R Power Dome R SnapConnect 13 Heavy

R 16 Standard 9 Available in 13 Heavy L: 10 Default tubing

R: AUDIOMETRIC INFORMATION

8mm-10mm

8mm-10mm

10mm-12mm

10mm-12mm

12mm-14mm

12mm-14mm

250 500 1000 1500 2000 3000 4000 6000 8000

LEFT AC

BC

RIGH

T AC

BC

SPEECH AUDIOMETRY

MCL (Most Comfortable Level) L ______ B ______ UCL (Uncomfortable Level) R ______ B ______L R

BILL TO: Account Number SHIP TO: Account Number

Facility Facility

Address Address

Phone Fax Phone Fax

Email Email

Contact Contact

P.O. No Amount

AMEX Discover Master Card Visa Money Order Starkey Government Services

6700 Washington Avenue South, Eden Prairie, MN 55344 Name on Card Expiration

VOICE: 866-418-6928 Credit Card Number Credit Card Security Code

Contract # 36C79119D0037

Date

Patient Last Name First Name Last 4 Digits of SSN

Government RIC Order FormContract Period: May 1, 2021-October 31, 2021

Government RIC Order Form Date

Patient Last Name First Name Last 4 Digits of SSN

Contract Period: May 1, 2021-October 31, 2021

RECEIVER–IN–CANAL WIRELESS RECEIVER-IN-CANAL MODELS CUSTOM EMBEDDED RECEIVER RECEIVER OPTIONS

L R L R

L R

40 dB Custom Receiver (107/40) L R

L R

L

L

L

R 40 dB

Livio Edge AI RIC R Livio Edge AI RIC R Livio RIC R L R

L R Livio Edge AI RIC 312

CROS Transmitter L R L R L R L R L R

50 dB Custom Receiver (115/50) Livio Edge AI RIC 312 R 50 dB CROS Transmitter Livio Edge AI Micro CROS Transmitter 60 dB Custom Receiver (119/60)

R 60 dBRIC 312Livio RIC R 65 dB Custom Receiver (123/65) 70 dB Custom Receiver (130/70)

STANDARD COLORS

L R L R L R

Champagne (Default) L R L R L R

Espresso L R White with Sterling RECEIVER LENGTH Please check one Sterling Slate

1 32 1

4 5 1Bronze Black L: R: 1 32 4 5

DOMES Please check one WIRELESS ACCESSORIES

SHT TV Streamer2 Table Microphone2 SurfLink Mini L (43005-610) (43044-600) Mobile System3 (64067-200)

SHT Remote Mic Plus2 SurfLink Media 2 SurfLink Remote L: (43006-610) (64155-000) Microphone 2 (64067-000)

R:SHT Mini Remote Mic2 SurfLink Advanced SurfLink Mini (43023-610) Remote (60111-002) Mobile Adapter4 (64368-000)

LSHT Remote Control2 SurfLink Basic Remote (43011-002) (60111-000) L:

R:

EARMOLDS EARMOLD STYLES VENT

L R Hollow Silicone RIC5 L R RIC Half Shell L R As Large as Possible L R Canal Earmold RIC L R RIC Semi Skeleton L R Select-a-Vent - 3.37 mm L R Canal Lock RIC L R Hollow Canal 40 L R Large Vent - 2.55 mm L R Skeleton RIC Earmold L R Standard/Medium Vent - 1.8 mm L R Helix RIC5 L R RIC Helix 40 L R Small Vent - 1.2 mm L R RIC Shell Earmold L R Pressure Vent - 0.8 mm

L R No Vent MATERIAL

1 Default receiver length 2 Compatible with Livio Edge AI and Livio 3 Includes SurfLink L R Lucite L R Silicone Remote Microphone 2 and SurfLink Mini Mobile Adapter 4 SurfLink Mini Mobile Adapter

is only compatible with the SurfLink Remote Microphone 2. 5 Only available in Silicone

Open L R Occluded

4mm (sleeve) 5mm 6mm 7mm 9mm 11mm

4mm (sleeve) 5mm 6mm 7mm 9mm 11mm

Power Dome

R

R

8mm–10mm 10mm–12mm 12mm–14mm

8mm–10mm 10mm–12mm 12mm–14mm

CUSTOM EMBEDDED OPTIONS MODIFICATIONS VENT

L R L R L R L R L R L R

Canal Length: Short Manufacturer Canal Length: Medium Selected Venting

Canal Length: Long Pressure Vent

Canal Tip: Red Mini Vent 2V

Canal Tip: Blue Medium Vent 3V

Removal String

L R

L R L R L R

MATERIAL

L R Lucite (Default)

AUDIOMETRIC INFORMATION 250 500 1000 1500 2000 3000 4000 6000 8000

LEFT AC

BC

RIGH

T AC

BC

BILL TO: Account Number SHIP TO: Account Number

Facility Facility

Address Address

Phone Fax Phone Fax

Email Email

Contact Contact

P.O. No Amount Starkey, the Starkey logo, Livio, Muse and SurfLink are registered trademarks of Starkey Laboratories, Inc. ©2021 Starkey. All Rights Reserved 85434-600 4/21 FORM3138-10-EE-GS

AMEX Discover Master Card Visa Money Order Starkey Government Services

6700 Washington Avenue South, Eden Prairie, MN 55344 Name on Card Expiration

VOICE: 866-418-6928 Credit Card Number Credit Card Security Code

Contract # 36C79119D0037

2