Form CMS-10028-A State Health Insurance Assistance Program (SHIP) Client

OMB 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)