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pdfOMB No. 0938-0850
State Health Insurance Assistance Program (SHIP) Client Contact Form (_ _)
Counselor Name:
Counseling Location Zip Code:
__ __ __ __ __
Date of Initial Contact:
__ __ / __ __ / __ __ __ __
month /
day
/
__ __ / __ __ / __ __ __ __
month /
day
Type of Contact:
q Quick call (<10 min)
q Telephone
/
(check one)
Agency (senior org, disability org,
Social Security)
Friend/Relative
Media (PSA, ad, newspaper, radio,
etc.)
Other: ______________________
Not Collected
Time Spent:
year
Date if Multiple Contact:
How Did Client Learn About the SHIP:
q CMS (1-800-Medicare,
q
www.Medicare.gov,
Medicare & You, CMS
q
mailing)
q
q Presentations/Fairs
q State-specific
q
mailings/brochures/
q
posters
Type of Client/Assistance
Requested by: (check all that
apply)
q Beneficiary (self)
q Couple
q Caregiver (family
member, conservator)
q Agency
Type of Contact:
q Quick call (<10 min)
q Telephone
q
q
q
In-Person (site)
In-Person (home visit)
E-mail/fax/postal mail
q
q
q
In-Person (site)
In-Person (home visit)
E-mail/fax/postal mail
_________ hours
_________ minutes
Time Spent:
year
_________ hours
_________ minutes
SECTION 1 – BENEFICIARY INFORMATION
Beneficiary Name:
____________________
Beneficiary Zip Code:
Last
Representative Name (if applicable):
____________________
__ __ __ __ __
____________________
First
Beneficiary Telephone #:
____________________
First
( __ __ __ ) __ __ __ - __ __ __ __
Last
o
SECTION 2 – BENEFICIARY DEMOGRAPHICS Is this his/her first contact with a SHIP since April 1?
Yes
o
No
(If Yes, Complete this section. If No, Skip to Section 3)
Age:
Monthly Income:
Date of Birth: __ __ / __ __ / __ __ __ __ OR
month / day /
year
q Under 65 years
q 65 – 74
q 75 – 84
q 85 or older
q Not Collected
Gender:
q Female
q Male
q Not Collected
Race/Ethnicity:
q
Below 150% of FPL
q
American Indian or Alaska Native
q
At or greater than 150% of FPL
q
Asian
q
Not Collected
q
Black or African American
$_____________
q
Hispanic or Latino
q
Native Hawaiian or other Pacific Islander
q
White, Not of Hispanic origin
q
Other
q
Not Collected
Disabled:
q Yes
q No
q Not Collected
SECTION 3 – TOPICS DISCUSSED (check all that apply)
Prescription Assistance:
Medicare Prescription Drug Coverage
(PDP/MA-PD):
q
Plan eligibility, benefit comparisons
q
Low-income assistance - eligibility, benefit
comparisons
q
Enrollment / application assistance
q
Claims / billing
q
Appeals/quality of care/complaints
Other Sources of Prescription Drug
Coverage/Assistance:
Medicare (Parts A and B):
q
Enrollment, eligibility, benefits
q
Claims/billing
q
Appeals/quality of care/complaints
Medicare Health Plans (HMOs, PPOs, PFFS,
Special Needs Plans):
q
Enrollment, disenrollment, eligibility,
comparisons
q
Plan or benefit changes/non-renewals
q
Claims/billing
q
Appeals/quality of care/complaints
q
Medicare-Approved Drug Discount Card
q
State Pharmacy Assistance Program
q
Union/Employer plan
q
QMB/SLMB/QI
q
Manufacturer’s Assistance Program
q
q
Other Medicaid
Discount plans
q
Other: ______________________
Medicaid (enrollment, eligibility, benefits):
Medigap/Supplement/SELECT:
q
Enrollment, eligibility,
comparisons
q
Change coverage
q
Claims/appeals
Other:
q
q
q
q
q
q
Long-Term Care
Fraud and Abuse
Military Health Benefits
Employer Health Plan or Federal
Employee Health Benefits
Program
Customer Service
issues/complaints
Other: _________________
Form CMS10028-A (0705)
OMB No. 0938-0850
Form CMS10028-A (0705)
| File Type | application/pdf |
| File Title | CC12.06.doc |
| Author | shierv |
| File Modified | 0000-00-00 |
| File Created | 2006-12-04 |