Client Contact Form Items Straight Text for 508 Compliant Document

CLIENT CONTACT

OMB No. 0985-0040

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	
3	Transgender	
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 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	
47	
48	
49	
50	
51	

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

24	Appeals/Grievances	OTHER

25	Fraud and Abuse		52	Long Term Care (LTC) Insurance	
26	Quality of Care		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	
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	

State and Local Special Use Fields	
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.