Complete the Online Certificate of Hearing Loss/Order Form

Step

Applicant Information

Name*

First Name

Middle Name

Last Name

Address*

Address (Line 1)

Address (Line 2)

City

State*

Zipcode

E-mail Address

* Please provide at least one phone number to continue.

Home Telephone

Work Telephone

Mobile Telephone

* Required information

Step

Healthcare Professional Information

Name*

First Name

Last Name

Title*

Occupation*

Physician

Audiologist

Hearing Related Professional

Government/Veterans Program

Business/Agency*

Address*

Address (Line 1)*

Address (Line 2)

City*

State*

Zipcode*

Telephone Number*

E-mail Address*

OEI Representative

Back

* Required information

Step

Order/Certification Information

High-speed Internet and telephone service is required for use of the Hamilton CapTel phone. Please select one of the following.*

The applicant has high-speed Internet and telephone service where the phone will be used.

The applicant does NOT have high-speed Internet. Please contact the applicant about other options. (Charges may apply depending on solution.)

Please select the applicant’s requested Hamilton CapTel phone.*

CapTel 840i

CapTel 2400i w/ Touchscreen

Notes

Applicant Authorization*

I certify that the applicant authorizes me to transmit this certification and the information contained herein to Hamilton CapTel.*

Healthcare Professional Certification*

I certify, under penalty of perjury, that: 1) this applicant has hearing loss that necessitates the use of Captioned Telephone Service; and 2) I understand that the service is provided by a live communications assistant and is funded through a federal program; and 3) I have not been offered or provided any direct or indirect incentive (financial or otherwise) tied to this consumer’s decision to use the service and I have not been referred to the applicant by a TRS provider or its affiliates; and 4) I don’t have a business (other than providing this form), family or social relationship with the TRS provider or its affiliates; and 5) no joint marketing arrangement exists between myself/my organization and Hamilton CapTel, and I have not made, nor do I have the opportunity to make, a profit on the sale of IP CTS equipment to consumers.*

Signature*

(Please sign below using your mouse.)

Clear

Back

Finish

* Required information

Complete the Online Certificate of Hearing Loss/Order Form

Live Chat is available during the following hours: