Form 7 SMP Media Outreach and Education Form

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

MEDIA OUTREACH AND EDUCATION FORM
* Items marked with asterisk (*) indicate required fields

Type of Interaction *:

Media Outreach & Education
Title of Interaction:

Session Conducted By*:
Date of Interaction (MM/DD/YYYY)*:

Time Spent in Minutes*:

End Date (if applicable):
Zip code*:

Reference Number: Auto-Populated

State*:

Organization: Auto-Populated

County:
Notes:

ACL/SMP Consumer Alert*:




Type of Media:

Yes
Billboard






Email
Magazine
Newsletter



County or Counties





Multi-State





Beneficiaries
Family Members/
Caregivers
General Audience









No

Newspaper
Radio
Social Media



National
Regional



Television
Website
Other




Number of Airings:
Geographic Coverage:

Statewide
Zip Code



Specific Coverage Location:
Intended Audience:






Health Care
Providers
Law
Enforcement




Topic(s) Discussed:













Conditional Payments
Consumer Protection
Durable Medical Equipment (DME)
Employer Health Plan
General Fraud Errors, and Abuse
Genetic/DNA Testing
Home Health Care
Hospice
Medicaid
Medical Identity Theft
Medicare Advantage
Medicare Part A and B

Other Topics Discussed Details:
Estimated Number of People Reached*:
Basis of Estimate of Number of People Reached:

In-Kind Match (xxxx.xx):













Medicare Part D
Medicare Summary Notice
Medigap or Supplemental Insurance
Medicare Card
Opioid Fraud and Abuse
SMP Program Information
SMP Volunteer Recruitment
Social Security
TRICARE
Veteran’s Health Benefit
Other

Partner
Organizations
Other

OMB Control Number: 0985-0040 Expires: Month/Day/2023
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 4 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.