Current MAPS Screens

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

1