SpeechVive Device Order Page

Shopping Cart

Review your purchase

Patient

Tell us about the patient

Insurance

Provide insurance info

Prescription

Doctor and diagnosis data

Review

Confirm and submit your request

Review your purchase

Which ear should I order SpeechVive?
Select the ear with the best hearing. If both are similar, select the ear you do not use on the telephone.

Select Ear:	Left Right

Quantity:

Payment:

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Your Email:	This address will be blind copied on the patient's email confirmation, which is needed for you to obtain the Sales Order number.

SpeechVive has partnered with SunMED as our exclusive Durable Medical Equipment (DME) provider.

Tell us about the patient

First Name

Last Name

Date of Birth

Gender

Contact Method

Cell Phone

Home Phone

Shipping Address

City

State

Zip

Provide insurance info

Enter Data I will enter my information directly on this form

- OR -

Upload Document I will upload pictures of my Insurance card

PRIMARY INSURANCE

Policy Holder Name

Policy Holder Date of Birth

Policy Holder Employer

Policy Holder Employer Phone

Insurance Carrier

Policy Number

Group Number

SECONDARY INSURANCE

Policy Holder Name

Policy Holder Date of Birth

Policy Holder Employer

Policy Holder Employer Phone

Insurance Carrier

Policy Number

Group Number

Doctor and diagnosis data

Contact Doctor Allow SunMED to contact my doctor on my behalf to retrieve this information

Enter Data I will be entering the diagnosis and doctor information directly on this form

- OR -

Upload Document I will upload the doctor's prescription and/or a completed Rx Form

Primary Diagnosis

Secondary Diagnosis

Tertiary Diagnosis

Doctor First Name

Doctor Last Name

Doctor Phone

Doctor NPI

Doctor First Name

Doctor Last Name

Doctor Phone

Doctor Address

Confirm and submit your request

Additional Notes
Name and contact information for speech therapist (if any), caregiver contact information, etc.