Form CMS-10028 CMS-10028. Client Contact Form

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CLIENT CONTACT
OMB No. 0938-0850

Client Identifiers - To Be Used To Lookup Clients With More Than One Contact and Link All Such Contacts Together
Client Identifier Used by Your Agency or State
Client Identifier Auto-Assigned by NPR - Optional

Client Name and Contact Information - Optional
Client First Name
Client Last Name
(__ __ __) - __ __ __ - __ __ __ __
Client Phone Number
Representative First Name
Representative Last Name

How Did Client Learn About SHIP
1 Previous Contact
2 CMS / Medicare
3 Presentations
4 Mailings
5 Another Agency
6 Friend or Relative
7 Media
8 State Website
9 Other
99 Not Collected

Client ZIP Code and County Code
ZIP Code of Client Residence
County Code of Client Residence - Optional

Counselor and Agency
Counselor User ID
Agency Code
County Code of Counselor Location
ZIP Code of Counselor Location

Date of Contact

/

/

First vs Continuing Contact
1 First Contact for Issue
2 Continuing Contacts for Issue

Method of Contact
1 Phone Call
2 Face to Face at Counseling Location or Event Site
3 Face to Face at Client's Home or Facility
4 E-Mail
5 Postal Mail or Fax

Client Age Group
1 64 or Younger
2 65-74
3 75-84
4 85 or Older
9 Not Collected

Client Gender
1 Female
2 Male
9 Not Collected

Client Race-Ethnicity - Check all that Apply
1 Hispanic, Latino, or Spanish Origin
2 White, Non-Hispanic
3 Black, African American
4 American Indian or Alaska Native
5 Asian Indian
6 Chinese
7 Filipino
8 Japanese
9 Korean
10 Vietnamese
11 Native Hawaiian
12 Guamanian or Chamorro
13 Samoan
14 Other Asian
15 Other Pacific Islander
16 Some Other Race-Ethnicity
99 Not Collected

Client Primary Language Other Than English
1 Primary Language Other Than English
2 English is Client's Primary Language
9 Not Collected

Client Monthly Income
1 Below 150% FPL
2 At or Above 150% FPL
9 Not Collected

Client Assets
1 Below LIS Asset Limits
2 Above LIS Asset Limits
9 Not Collected

Receiving or Applying for Social Security
Disability or Medicare Disability
1 Yes
2 No
9 Not Collected

Dual Eligible with Mental Illness / Mental Disability
1 Yes
2 No
9 Not Collected

PRESCRIPTION DRUG ASSISTANCE
Medicare Prescription Drug Coverage (Part D)
1
Eligibility/Screening
2
Benefit Explanation
3
Plans Comparison
4
Plan Enrollment/Disenrollment
5
Claims/Billing
6
Appeals/Grievances
7
Fraud and Abuse
8
Marketing/Sales Complaints or Issues
9
Quality of Care
10
Plan Non-Renewal
Part D Low Income Subsidy (LIS/Extra Help)
11
Eligibility/Screening
12
Benefit Explanation
13
Application Assistance
14
Claims/Billing
15
Appeals/Grievances
Other Prescription Assistance
16
Union/Employer Plan
17
Military Drug Benefits
18
Manufacturer Programs
19
State Pharmaceutical Assistance Programs
20
Other ______________________________
MEDICARE (Parts A & B)
21
Eligibility
22
Benefit Explanation
23
Claims/Billing
24
Appeals/Grievances
25
Fraud and Abuse
26
Quality of Care

MEDICARE ADVANTAGE (HMO, POS, PPO, PFFS, SNP, MSA, Cost)
27
Eligibility/Screening
28
Benefit Explanation
29
Plans Comparison
30
Plan Enrollment/Disenrollment
31
Claims/Billing
32
Appeals/Grievances
33
Fraud and Abuse
34
Marketing/Sales Complaints or Issues
35
Quality of Care
36
Plan Non-Renewal
MEDICARE SUPPLEMENT/SELECT
Eligibility/Screening
37
38
Benefit Explanation
39
Plans Comparison
40
Claims/Billing
41
Appeals/Grievances
42
Fraud and Abuse
43
Marketing/Sales Complaints or Issues
44
Quality of Care
45
Plan Non-Renewal
MEDICAID
46
Medicare Savings Programs (MSP) Screening (QMB, SLMB, QI)
MSP Application Assistance
47
Medicaid (SSI, Nursing Home, MEPD, Elderly Waiver) Screening
48
49
Medicaid Application Assistance
50
Medicaid/QMB Claims
51
Fraud and Abuse
OTHER
52
Long Term Care (LTC) Insurance
53
LTC Partnership
54
LTC Other
55
Military Health Benefits
56
Employer/Federal Employee Health Benefits (FEHB)
57
COBRA
58
Other Health Insurance
59
Other _______________________________________

Total Time Spent on This Contact Date
HH
Hours
MM
Minutes

Status
1 General Information and Referral
2 Detailed Assistance - In Progress
3 Detailed Assistance - Fully Completed
4 Problem Solving / Problem Resolution - In Progress
5 Problem Solving / Problem Resolution - Fully Completed

Nationwide and CMS Special Use Fields
01
02
03
04
05
06
07

08

09

10

State and Local Special Use Fields
01
02
03
04
05
06

08

09

10

07

Form CMS-10028A (07/13)

PRA Disclosure Statement

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it
displays a valid OMB control number. The valid OMB control number for this information collection is 0938-0850. The time
required to complete this information collection is estimated to average 5 minutes per response, including the time to review
instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you
have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS,
7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.