Document

Current MAPS Screens

ICR 201902-0960-001 · OMB 0960-0696 · Object 88918201.

This document may belong to an older filing. More recent activity for OMB 0960-0696:

2021-06-03 · Revision of a currently approved collection

Document Viewer [docx]

Status: Original and derived artifacts are available for this document.

Download: docx | pdf | html

Primary: docxSource: application/vnd.openxmlformats-officedocument.wordprocessingml.document

Loading document viewer…

Document Metadata

Record metadata
File Type	application/vnd.openxmlformats-officedocument.wordprocessingml.document
File Title	Current MAPS Screens
Author	Netherton, Linnet
Last Modified By	Writer
File Modified	2019-02-01
File Created	2026-09-13
Conversion State	complete

Extracted Text

Current Screens
 Justification for Non-Substantive Change to

Form SSA-1020/i1020
Application for Extra Help with Medicare Prescription Drug Plan Costs

OMB No. 0960-0696 – Current Screens
Change 1:

Current MEDQ Default Screen (QDIS)
Current QDIS display: Client Data section (Part A tab)

Client Data
Name:
Medicare Claim#: Title2 Claim#: SSI Claim#:
RRB Claim#: Date of Birth: Sex:
Address:
Source of Address:	MBR
Phone Number: Couples X ref#:
Preferred Language:
    • Spoken:	English
    • Written:	English


Current QDIS display: Client Data section (Part B tab)

Client Data
Name:
Medicare Claim#: Title2 Claim#: SSI Claim#:
RRB Claim#: Date of Birth: Sex:
Address:
Source of Address:	MBR
Phone Number: Couples X ref#: Preferred Language:
    • Spoken:	English
    • Written:	English

Current QDIS display: Client Data section (Part C tab)

Client Data
Name:
Medicare Claim#: Title2 Claim#: SSI Claim#:
RRB Claim#: Date of Birth: Sex:
Address:
Source of Address:	MBR
Phone Number: Couples X ref#: Preferred Language:
    • Spoken:	English
    • Written:	English
Current QDIS display: Applicant Data section (Part D & ‘All’ tab)

Applicant Data
Current Application Status:	Completed - Determined/Done 2019 No
Deemed:
2018 No
2017 No
Medicare Savings Program (Referral):	Yes
Name:
Medicare Claim#: Title2 Claim#: SSI Claim#:
RRB Claim#:
Date of Birth: Sex:
Type of Application: Contact Type:
Source of Application:	Paper
Address:
Source of Address:	MBR
Phone Number:	Other
Couples X ref#: Preferred Language:
    • Spoken:	English
    • Written:	English

Current QDIS display: Spouse Data section (Part D & ‘All’ tab)

Spouse Data
Current Application Status:	Completed - Determined/Done 2019 No
Deemed:
2018 No
2017 No
Medicare Savings Program (Referral):	Yes
Name:
Medicare Claim#: Title2 Claim#: SSI Claim#:
RRB Claim#:
Date of Birth: Sex:
Type of Application: Contact Type:
Source of Application:	Paper
Address:
Source of Address:	MBR
Phone Number:	Other
Couples X ref#: Preferred  Language:
    • Spoken:	English
    • Written:	English