Form 1 Beneficiary Client Form

BENEFICIARY CONTACT FORM

OMB No. 0985-0040

* Items marked with asterisk (*) indicate required fields
 Yes

 No

Send to SMP:
 Yes
Counselor Information *
Session Conducted By* :

 No

MIPPA Contact *:

SIRS eFile ID:
(*required if sending record to SMP)
ZIP Code of Session Location * :

Partner Organization Affiliation* :

State of Session Location * :

County of Session Location * :

Beneficiary & Representative Name and Contact Information
Beneficiary First Name:

Representative First Name:

Beneficiary Last Name:

Representative Last Name:

Beneficiary Phone: (

)-

-

Representative Phone: (

Beneficiary Email:

)-

-

Representative Email:

Beneficiary Residence *
State of Bene Res. * :

Zip Code of Bene Res. * :

County of Bene Res. * :

Date of Contact *:
How Did Beneficiary Learn About SHIP * (select only one):
 Previous Contact
 SHIP Mailings
 SHIP Media
 SHIP Presentation
 State SHIP Website
Method of Contact * (select only one):

 CMS Outreach
 Congressional Office
 Friend or Relative
 Health/Drug Plan
 Partner Agency

 Phone Call
 Email
 Web-based
 Postal Mail

 Face

to Face at
Session Location/
Event Site

 Face

to Face at
Bene Home/
Facility

or Fax
Beneficiary Race * (multiple selections allowed):
 American Indian or Alaska
 Native Hawaiian or
Native
Other Pacific Islander
 Asian
 White
 Not Collected
 Black or African American
 Hispanic or Latino

 SHIP TA Center
 SSA
 State Medicaid Agency
 1-800 Medicare

 Other
 Not Collected

Beneficiary Age Group *
(select only one):
 64 or Younger
 85 or Older
 65 – 74
 Not Collected
 75 – 84

Beneficiary Gender *
(select only one):
 Female
 Male
 Other
 Not Collected

Beneficiary Language *:
English is Beneficiary’s Primary
 Yes
 No
Language
Receiving or Applying for Social Security Disability or
Medicare Disability * (select only one):


Yes

 No

 Below 150% FPL

Beneficiary Monthly Income * (select only one):
 Not Collected

Beneficiary Assets * (select only one):
 Below LIS Asset Limits
 Not Collected

 At



or Above 150% FPL

Above LIS Asset Limits

Topics Discussed * (At least one Topic Discussed selection is required. Multiple selections allowed)
 Appeals/Grievances
 Benefit Explanation
Original
Medigap
 Benefit Explanation
 Claims/Billing
Medicare
and
 Eligibility/Screening
(Parts A & B)  Claims/Billing
Medicare
 Coordination of Benefits
 Fraud and Abuse
Select
 Eligibility
 Marketing/Sales Complaints & Issues
 Enrollment/Disenrollment
 Plan Non-Renewal
 Fraud and Abuse
 Plans Comparison
 QIO/Quality of Care

Topics Discussed (multiple selections allowed) (continued from p.1)*
Medicare Advantage (MA and MA-PD)
 Appeals/Grievances
 Benefit Explanation
 Claims/Billing
 Disenrollment
 Eligibility/Screening
 Enrollment
 Fraud and Abuse
 Marketing/Sales Complaints & Issues
 Plan Non-Renewal
 Plans Comparison
 QIO/Quality of Care

Medicaid
 Application Submission
 Benefit Explanation
 Claims/Billing
 Eligibility/Screening
 Fraud and Abuse
 Medicaid Application Assistance
 Medicare Buy-in Coordination
 Medicaid Managed Care
 MSP Application Assistance
 Recertification
 Other

Medicare Part D
 Appeals/Grievances
 Benefit Explanation
 Claims/Billing
 Disenrollment
 Eligibility/Screening
 Enrollment
 Fraud and Abuse
 Marketing/Sales Complaints & Issues
 Plan Non-Renewal
 Plans Comparison

Other Insurance
 Active Employer Health Benefits
 COBRA
 Indian Health Services
 Long Term Care (LTC) Insurance
 LTC Partnership
 Other Health Insurance
 Retiree Employer Health Benefits
 Tricare For Life Health Benefits
 Tricare Health Benefits
 VA/Veterans Health Benefits
 Other

Part D Low Income Subsidy (LIS/Extra Help)
 Appeals/Grievances
 Application Assistance
 Application Submission
 Benefit Explanation
 Claims/Billing
 Eligibility/Screening
 LI NET/BAE
Other Prescription Assistance
 Manufacturer Programs
 Military Drug Benefits
 State Pharmaceutical Assistance Programs
 Union/Employer Plan
 Other
Total Time Spent on This Contact *
Hours

Minutes

Additional Topic Details
 Ambulance
 Dental/Vision/Hearing
 DMEPOS
 Duals Demonstration
 Home Health Care
 Hospice
 Hospital
 New Medicare Card
 New to Medicare
 Preventive Benefits
 Skilled Nursing Facility

Status *


Special Use Fields
Original PDP/MA-PD Cost: _
New PDP/MA-PD Cost:

Notes

Field 3:
Field 4:
Field 5:

In Progress



Completed