My Essentials

Enrollment Form

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    Step 1

    Key Code

    Company Name Enter the company name here that you want us to use as your main company of record. If you have more than one company, we will ask for that information later.

    Company Address Enter the main address here that you want us to use as your main address of record. If you have multiple locations, we will ask for that information later




    Company Contact Enter the main company contact here. If you want to delegate a different contact for other companies/locations, we will ask for that information later.

    Company Contact Email Enter the main company contact email here.

    Do you operate under more than one Company name? If you operate under more than one Company, we will collect information on each company.

    How many locations do you have? Include any location where you see patients and make hearing instrument sales.

    Enter the address of each location. We need the physical address of each location for compliance with insurance laws and to make commission payments




    Upload Product Price List. We need your product price list to ensure your products fit within our program pricing. We WILL NOT share your product price list with any other parties.

    Step 2

    Review and Acknowledge Training Requirement

    Check to Acknowledge

    Review and Acknowledge Governing Rules

    Check to Acknowledge

    Program Terms

    Agree to only enroll eligible customers with working hearing instruments
    Acknowledge My Essentials will not share any of their information as set forth in our Confidentiality Commitment link
    Agree to pass on wholesale costs
    Acknowledge commission reduction is loss ratio > 20%
    Acknowledge commission reduction for reasonable marketing materials expenses
    Agree to not submit any false information
    Define reimbursement rates per manufacturer – instead of updating product list?
    Agree to enroll customers timely and accurately
    Agree to report claims timely and accurately

    Check to Acknowledge