Form 1 Beneficiary Contact Form

OMB Control Number: 0985-0040 Expiration: Month/Day/2023

BENEFICIARY CONTACT FORM
* Items marked with asterisk (*) indicate required fields
OMIPPA Contact
*:

 Yes

 No

SIRS eFile ID:
 Yes
 No
Send to SMP:
(*required if sending record to SMP)
Counselor Information *
Session Conducted By* :
ZIP Code of Session Location * :
State of Session Location * :
___________________________________________
___________________________
__________________
Partner Organization Affiliation* :
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
 Black or African American
 Not Collected
 Hispanic or Latino
Have you or a family member ever served in the military?
 No

 Yes

Beneficiary Monthly Income * (select only one):
 Below 150% FPL
 Not Collected

 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

 Unsure

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)
 Accountable Care Organizations (ACOs)
 Equitable Relief
Original
 Appeals/Grievances
 Fraud and Abuse
Medicare
 Late Enrollment Penalty
(Parts A & B)  Benefit Explanation
 Claims/Billing
 Provider Participation
 Conditional Enrollment
 QIO/Quality of Care
 Coordination of Benefits
 Eligibility
 Enrollment/Disenrollment
Topics Discussed (multiple selections allowed) (continued from p.1)*
Medigap and Medicare Select
 Application Assistance
 Benefit Explanation
 Claims/Billing
 Complaints
 Eligibility/Screening
 Fraud and Abuse
 Guaranteed Issue Rights
 Plan Non-Renewal
 Plans Comparison
Medicare Advantage (MA and MA-PD)
 Appeals/Grievances
 Benefit Explanation
 Claims/Billing
 Chronic Condition Special Needs Plans
 Disenrollment
 Dual Eligible Special Needs Plans
 Eligibility/Screening
 Enrollment
 Fraud and Abuse
 Institutional Special Needs Plans
 Marketing/Sales Complaints & Issues
 Plan Non-Renewal
 Plans Comparison
 Provider Network
 QIO/Quality of Care
 Supplemental Benefits (please explain)
Medicare Part D
 Appeals/Grievances
 Benefit Explanation
 Claims/Billing
 Disenrollment
 Eligibility/Screening
 Enrollment
 Fraud and Abuse
 Late Enrollment Penalty
 Pharmacy Network
 Marketing/Sales Complaints & Issues
 Plan Non-Renewal
 Plans Comparison
Part D Low Income Subsidy (LIS/Extra Help)
 Appeals/Grievances
 Application Assistance
 Application Submission
 Benefit Explanation
 Claims/Billing

Medicaid
 Appeals/Grievances
 Benefit Explanation
 Claims/Billing
 Duals Demonstration
 Eligibility/Screening
 Fraud and Abuse
 Medicaid Application Assistance
 Medicaid Application Submission
 Medicaid Expansion (ACA) Transition to
Medicare
 Medicaid Recertification
 Medicare Buy-in Coordination
 Medicaid Managed Care
 Medicaid Spend Down
 MSP Application Assistance
 MSP Application Submission
 MSP Recertification
 Program of All-Inclusive Care for the Elderly
(PACE)
 Provider Participation
 QMB Improper Billing
Other Insurance
 Active Employer Health Benefits
 COBRA
 Indian Health Services
 Long Term Care (LTC) Insurance
 LTC Partnership
 Marketplace Transition to Medicare
 Other Health Insurance
 Retiree Employer Health Benefits
 Tricare For Life Health Benefits
 Tricare Health Benefits
 VA/Veterans Health Benefits
Additional Topic Details
 Ambulance
 COVID-19
 Dental/Vision/Hearing
 DMEPOS
 ESRD
 Health Savings Account(s)
 Home Health Care
 Hospice
 Hospital
 Income Related Monthly Adjustment Amount
 Mail Order Prescription
 Medicare Card














Eligibility/Screening
LI NET/BAE

Other Prescription Assistance
 Manufacturer Programs
 Military Drug Benefits
 Prescription Discount Cards
 State Pharmaceutical Assistance Programs
 Union/Employer Plan
Total Time Spent on This Contact *
____ Hours _______

Minutes

Mental Health
MyMedicare.gov Account
New to Medicare
Opioids
Physical Therapy
Preventive Benefits
Skilled Nursing Facility
Telehealth
Transportation

Status *


In Progress



Completed

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

_______________

Field 3: _______________
Field 4: _______________
Field 5: _______________

Notes

Public Burden Statement:
According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless such
collection displays a valid OMB control number (OMB 0985-0040). Public reporting burden for this collection of information
averages 5 minutes per response, including time for gathering, maintaining, completing and reviewing the collection of information.
The obligation to respond to this collection is required to retain or maintain benefits under the statutory authority from Section 4360(f)
of the OBRA.