Starkey Government RIC Genesis AI Order Form
This file is an order form for Starkey's Government RIC (Genesis AI) products for the contract period May 1, 2024 - October 31, 2024. It includes fields for patient information, model selection, accessories, and earmolds. This form is used to order hearing aid related products from Starkey Laboratories.
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How do I fill this out?
Filling out this form requires accurate information about the patient and product specifications. You will need to select from various options including receiver-in-canal models, colors, and accessories. Make sure to review your selections carefully before submission.
How to fill out the Starkey Government RIC Genesis AI Order Form?
1
Enter patient information.
2
Select receiver-in-canal models and colors.
3
Choose the appropriate wireless accessories.
4
Fill out the earmold options and modifications.
5
Complete the billing and shipping information.
Who needs the Starkey Government RIC Genesis AI Order Form?
1
Healthcare providers who need to order Starkey hearing aids for their patients.
2
Government agencies that have a contract with Starkey Laboratories for hearing aid supplies.
3
Audiologists who need to specify detailed product options for patients.
4
Administrators who handle medical supply orders within healthcare facilities.
5
Patients who need to provide their personal information and preferences for hearing aid orders.
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What are the instructions for submitting this form?
Submit the completed form to Starkey Government Services. Use the following contact details for submission: Email: govorders@starkey.com, Fax: 866-418-6928, Physical Address: Starkey Government Services, 6700 Washington Avenue South, Eden Prairie, MN 55344. Ensure all required fields are completed and reviewed for accuracy before submission. Make sure to include any necessary attachments and follow up with Starkey if you do not receive a confirmation of receipt.
What are the important dates for this form in 2024 and 2025?
Contract Period: May 1, 2024 - October 31, 2024.
What is the purpose of this form?
The purpose of this form is to facilitate the ordering of Starkey's Government RIC (Genesis AI) hearing aid products for the specified contract period. It includes various fields to capture patient information, product specifications, and additional accessories required for the order. This form ensures that healthcare providers, audiologists, and government agencies can accurately request the needed Starkey hearing aid supplies for their patients.
Tell me about this form and its components and fields line-by-line.
- 1. Patient Information: Includes fields for patient’s last name, first name, date, and last 4 digits of SSN.
- 2. Receiver-in-Canal Models: Selection of various Genesis AI RIC models for both left and right ears.
- 3. Colors: Options to choose the color of the RIC, including Beige, Caramel, Chestnut, and others.
- 4. Wireless Accessories: Includes StarLink TV Streamer, Remote Mic Plus, Mini Remote Mic, and Remote Control 2.0.
- 5. Domes: Selection of different dome sizes and types, such as Open, Occluded, Power Dome, etc.
- 6. Chargers: Options for different charger models, including StarLink Premium Charger 2.0.
- 7. Earmolds: Selection of earmold styles, materials, vent sizes, and custom modifications.
- 8. Audiometric Information: Fields for audiometric data including AC and BC readings at various frequencies.
- 9. Billing Information: Includes account number, payment method, and credit card details.
- 10. Shipping Information: Fields for facility name, address, contact details, and shipping preferences.
What happens if I fail to submit this form?
Failure to submit this form may result in delays or denial of orders.
- Delayed Orders: Important hearing aid supplies may not be received on time.
- Order Denial: Incomplete or incorrect submissions can lead to the rejection of the order.
- Patient Impact: Lack of timely hearing aid support can affect patient care and well-being.
How do I know when to use this form?
- 1. New Orders: For placing new hearing aid orders within the contract period.
- 2. Product Upgrades: When requesting upgrades or new models for existing patients.
- 3. Accessory Requests: To order additional wireless accessories and earmolds.
- 4. Billing Updates: When updating billing information and payment methods.
- 5. Shipping Changes: To modify shipping preferences or facility details.
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