Form 8 SMP Group Outreach and Education

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

GROUP OUTREACH AND EDUCATION FORM
* Items marked with asterisk (*) indicate required fields
Type of Interaction *:

Group Outreach & Education
Title of Interaction:

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

Time Spent in Minutes*:

End Date (if applicable):
Zip code*:

State*:

Reference Number: Auto-Populated

County:

Organization: Auto-Populated

Notes:

ACL/SMP Consumer Alert*:

Type of Event:

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Yes

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No

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Community Event
Group Education Session

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Beneficiaries
Family Members/Caregivers
General Audience
Health Care Providers

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Intended Audience:

Targeted Beneficiary
Audience(s):

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Law Enforcement
Partner Organizations
Other

General
Homebound

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Non English Speaking
People with Disabilities
Racial/Ethnic Minority

Long Term Care Residents
Low Income
Native American

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Rural
Not Collected

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Other

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Topic(s) Discussed:
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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 Card

Other Topics Discussed Details:
Estimated Number of People Reached*:
In-Kind Match (xxxx.xx):

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Medicare Part A and B
Medicare Part D

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Medicare Summary Notice
Medigap or Supplemental Insurance
Opioid Fraud and Abuse
SMP Program Information
SMP Volunteer Recruitment
Social Security
TRICARE

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Veteran’s Health Benefits (VA)
Other

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OMB Control Number 0985-0040 Expires: Month/Day/2023
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collection displays a valid OMB control number (OMB 0985-0040). Public reporting burden for this collection of information averages
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obligation to respond to this collection is required to retain or maintain benefits under the statutory authority from Section 4360(f) of the
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