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INSURANCE COVERAGE IS PEACE OF MIND PROTECTION FOR YOUR HEARING INSTRUMENTS.

If you have used Veterans Administration hearing benefits for these hearing instruments, please disregard this extended insurance coverage offer. Replacement coverage is managed through the Veterans Administration.

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Patient Information

First Name *

Middle Name

Last Name *

Guardian / CO First Name

Guardian / CO Last Name

Address *

City *

State *

ZIP Code *

Phone*

Date of Birth *

Email Address *

Practitioner Information

Practitioner State *

Practitioner Office *

Office Name *

Office Address *

Office City *

Practitioner State *

Zip *

Office Phone*

Devices

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Coverage Options

SELECTED	COVERAGE	PAYMENT	PREMIUM
	Protection Plus	Annual	0.00
	Protection Plus	Monthly	0.00
	Platinum Plan	Annual	0.00
	Platinum Plan	Monthly	0.00