Form 1 Client Contact Form

State Health Insurance Assistance Program (SHIP) Client Contact Form, Pubic and Media Activity Form, and Resource Report Form

Client Contact Form Items Straight Text - For 508 Compliant Document - 0....rtf

Client Contact Form

OMB: 0985-0040

^C^o^un^s^e^l^o^r
aⁿ^d^Ag^eⁿ^c^y

Counselor User ID

^Ag^eⁿ^cy^C^o^d^e

^C^o^un^ty^C^o^d^e^o^f^C^o^un^s^e^l^o^r^Lo^c^a^ti^oⁿ

^ZIP^C^o^d^e^o^f^C^o^un^s^e^l^o^r^L^o^c^a^ti^oⁿ

⚠️ Notice: This form may be outdated. More recent filings and information on OMB 0985-0040 can be found here:

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Client Contact Form Items Straight Text for 508 Compliant Document

CLIENT CONTACT

Shape1 _O_MB_N_o.₀₉₈₅_-₀₀₄₀

^Clieⁿ^t^I^d^eⁿ^tifie^r^s^-^T^o^B^e^U^s^ed To^L^o^o^k^u^p Clieⁿ^t^s^With^Mo^r^e^T^h^an^Oⁿ^e^C^oⁿ^ta^c^t^aⁿ^d^Lⁱⁿ^k^A^ll^Su^ch^C^oⁿ^ta^c^ts^T^og^et^h^er
Client Identifier Used by Your Agency or State
^Clieⁿ^t^I^d^eⁿ^tifier^Au^t^o^-^A^ssi^gn^e^d^b^y^NP^R^{- O}^p^ti^oⁿ^al

Client Name and Contact Information - Optional

Client First Name

Client Last Name

Client Phone Number ( __) - - Representative First Name

Representative Last Name

^H^o^w^D^id Clieⁿ^t^L^e^arn^Ab^o^u^t^SH^IP
1	Previous Contact
²	^C^M^S^/^Me^d^ica^r^e
³	^P^re^s^eⁿ^tatⁱ^oⁿ^s
⁴	^M^aili^ng^s
⁵	^An^o^t^h^e^r^Ag^eⁿ^cy
⁶	^F^ri^eⁿ^d^o^r^R^e^latⁱ^v^e
⁷	^Me^d^ia
⁸	^S^tate^We^b^sⁱ^te
⁹	^Ot^h^er
⁹⁹	^N^o^t^C^o^ll^e^cted

^Clieⁿ^t^ZIP^C^o^d^e^aⁿ^d^C^o^un^ty^C^o^d^e
ZIP Code of Client Residence
^C^o^un^ty^C^o^d^e^o^f^Clieⁿ^t^Resⁱ^d^eⁿ^ce^{- O}^p^ti^oⁿ^al

^D^ate^o^f^C^oⁿ^tact

^F^irst^v^s^C^oⁿ^ti^nuⁱⁿ^g C^oⁿ^ta^c^t
1	First Contact for Issue
²	^C^oⁿ^ti^nuⁱⁿ^g^C^oⁿ^tacts^f^o^r^Is^s^u^e

^M^et^h^o^d^o^f^C^oⁿ^tact
1	Phone Call
²	^F^ace^t^o^F^a^ce^a^t^C^o^un^seliⁿ^g^L^o^catⁱ^oⁿ^o^r^E^v^eⁿ^t^Sⁱ^t^e
³	^F^ace^t^o^F^a^ce^a^t^Clieⁿ^t^'^s^Ho^m^e^o^r^F^a^cility
⁴	^E-^M^ail
⁵	^P^o^stal^M^ail^o^r^F^ax

^Clieⁿ^t^Ag^e^G^r^o^u^p
1	64 or Younger
²	⁶⁵^-⁷⁴
³	⁷⁵^-⁸⁴
⁴	⁸⁵^o^r^Ol^d^e^r
⁹	^N^o^t^C^o^ll^e^cted

^Clieⁿ^t^Ge^nd^er
1	Female
²	^M^ale
³	^Traⁿ^s^g^e^nd^e^r
⁹	^N^o^t^C^o^ll^e^cted

^Clieⁿ^t^Ra^c^e^-Et^hn^ici^t^y^{- C}^h^e^c^k^{all t}^h^at^App^ly
1	Hispanic, Latino, or Spanish Origin
²	^W^h^ite,^N^oⁿ^-^H^is^p^aⁿ^ic
³	^Blac^k^,^A^frⁱ^can^A^me^rican
⁴	^A^me^rⁱ^can I^nd^ian^o^r^A^laska^N^ati^v^e
⁵	^A^sian I^nd^ian
⁶	^C^hⁱⁿ^e^se
⁷	^F^ili^pⁱⁿ^o
⁸	^J^a^p^aⁿ^e^se
⁹	^K^o^r^ean
¹⁰	^V^ietⁿ^a^m^e^s^e
¹¹	^N^ati^v^e^H^awaiian
¹²	^G^u^a^m^aⁿ^ian^o^r C^h^a^m^o^rro
¹³	^S^a^m^o^an
¹⁴	^Ot^h^e^r^A^sian
¹⁵	^Ot^h^er^P^acifⁱ^c^Isla^nd^e^r
¹⁶	^So^m^e^Ot^h^e^r^Rac^e^-^E^t^hn^icity
⁹⁹	^N^o^t^C^o^ll^e^cted

^Clieⁿ^t^P^ri^m^a^r^y^L^a^ngu^a^g^e^O^t^h^e^r T^h^an E^ng^lish
1	Primary Language Other Than English
²	^E^ng^{lish is Clie}ⁿ^t^'^s^P^rⁱ^m^a^r^y^L^a^ngu^a^g^e
⁹	^N^o^t^C^o^ll^e^cted

^Cli^eⁿ^t^M^oⁿ^t^h^l^y^Iⁿ^c^om^e
1	Below 150% FPL
²	^A^t^o^r^Abo^v^e¹⁵⁰^%^FP^L
⁹	^N^o^t^C^o^ll^e^cted

^Clieⁿ^t^A^ss^e^ts
1	Below LIS Asset Limits
²	^Ab^o^v^e^L^IS^A^sset^Lⁱ^m^its
⁹	^N^o^t^C^o^ll^e^cted

^R^e^c^eⁱ^vⁱⁿ^g^o^r^App^l^yⁱⁿ^g f^o^r^S^o^cial^S^e^c^u^rity
^D^isa^b^ility^o^r^M^e^d^icare^D^is^a^b^ility
1	Yes
²	^N^o
⁹	^N^o^t^C^o^ll^e^cted

^D^u^al Eli^gⁱ^b^le^with^Meⁿ^tal Il^lⁿ^e^ss^/^M^eⁿ^tal^D^isa^b^ility
1	Yes
²	^N^o
⁹	^N^o^t^C^o^ll^e^cted

PRESCRIPTION DRUG ASSISTANCE MEDICARE ADVANTAGE (HMO, POS, PPO, PFFS, SNP, MSA, Cost)

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

Eligibility/Screening Benefit Explanation Plans Comparison

²⁷
28
29
30
31
32
33
34
35
36

Plan Enrollment/Disenrollment Claims/Billing Appeals/Grievances

Fraud and Abuse

Marketing/Sales Complaints or Issues

Quality of Care

Plan Non-Renewal

MEDICARE SUPPLEMENT/SELECT

³⁷
38
39
40
41
42
43
44
45

Eligibility/Screening Benefit Explanation Plans Comparison Claims/Billing Appeals/Grievances Fraud and Abuse

Marketing/Sales Complaints or Issues

Quality of Care

Plan Non-Renewal

⁴⁶

18 Manufacturer Programs MEDICAID

19 State Pharmaceutical Assistance Programs

20 Other

MEDICARE (Parts A & B)

21 Eligibility

22 Benefit Explanation

23 Claims/Billing

Medicare Savings Programs (MSP) Screening (QMB, SLMB, QI) MSP Application Assistance

Medicaid (SSI, Nursing Home, MEPD, Elderly Waiver) Screening

Medicaid Application Assistance

Medicaid/QMB Claims

Fraud and Abuse

Shape2 24 Appeals/Grievances OTHER

²⁵	^F^ra^u^d aⁿ^d^Abu^se	⁵²	^L^oⁿ^g T^e^r^m^Care⁽^L^T^C⁾^Iⁿ^s^u^raⁿ^ce
²⁶	^Q^u^ali^t^y^o^f^Care	⁵³	^L^TC^P^a^r^tⁿ^e^rs^h^ip
		⁵⁴	^L^TC^Ot^h^er
		⁵⁵	^M^ilita^r^y^H^e^alth B^eⁿ^e^fits
		⁵⁶	^E^m^p^l^o^y^e^r^/^F^e^d^eral^E^m^p^l^o^y^ee^H^ea^l^th Beⁿ^efits⁽^F^E^H^B)
		⁵⁷	^COBRA
		⁵⁸	^Ot^h^e^r^H^e^alth Iⁿ^s^u^raⁿ^c^e
		⁵⁹	^Ot^h^er

^T^o^tal^Tⁱ^m^e^Sp^eⁿ^t^oⁿ^T^h^is^C^oⁿ^tact^D^a^te
HH	Hours	MM	Minutes

^S^tat^u^s
1	General Information and Referral
²	^D^e^tailed^A^ssi^s^taⁿ^ce^{- In}^P^r^o^g^r^e^ss
³	^D^e^tailed^A^ssi^s^taⁿ^ce^-^Fu^lly^C^o^m^p^let^e^d
⁴	^P^r^o^b^l^e^m^S^o^l^vⁱⁿ^g /^P^r^o^b^l^e^m^R^e^s^o^l^u^ti^oⁿ^{- In}^P^r^o^g^r^e^s^s
⁵	^P^r^o^b^l^e^m^S^o^l^vⁱⁿ^g /^P^r^o^b^l^e^m^R^e^s^o^l^u^ti^oⁿ^-^Fu^lly^C^o^m^p^le^t^e^d

^N^ati^oⁿ^wi^d^e^aⁿ^d C^M^S^Sp^e^cⁱ^al Use^Fⁱ^e^l^d^s
01	02	03	04	05	06	07	08	09	10
Nationwide and CMS Special Use Fields
11	12	13	14	15	16	17	18	19	20
Nationwide and CMS Special Use Fields
21	22	23	24	25	26	27	28	29	30

^S^tate^aⁿ^d^L^o^cal^Sp^e^cial^Use^F^iel^d^s
01	02	03	04	05	06	07	08	09	10

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 0985-0040. 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: ACL, 330 C St SW, Attn: (OHIC) Office of Healthcare Information Counseling, Washington, DC 20024.

File Type	text/rtf
Author	Dennis Nalty
Last Modified By	Windows User
File Modified	2016-06-29
File Created	2016-06-29