Form 9 SMP Individual Interaction Basic Interaction Form

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

INDIVIDUAL INTERACTION: BASIC INTERACTION FORM
* Items marked with asterisk (*) indicate required fields
Type of Interaction*:
Individual Interaction
Session Conducted By*:

Title of Interaction:

Date of Interaction (MM/DD/YYYY)*:
End Date (if applicable):

Time Spent in Minutes*:

Zip code*:

Reference Number: Auto-Populated

State*:

Organization: Auto-Populated

County:
Notes:
Beneficiary Name and Contact Information
Beneficiary First Name:

Beneficiary Address:

Beneficiary Last Name:
Beneficiary Phone: (

)-

Beneficiary

-

City:

Beneficiary State:

Beneficiary Email:

Beneficiary Zip Code:
Beneficiary Demographic Information
 American Indian or Alaskan Native
Race
 Asian
(Multiple selections
 Black or African American
allowed):
 Hispanic or Latino
 Female
Gender (Select only one):
 Male
Date of Birth (MM/DD/YYYY):
Medicare Number:
Medicaid Number:
Other Information:
Permission to Contact Beneficiary?
Topic(s) Discussed:
 Conditional Payments
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Consumer Protection
Durable Medical
Equipment (DME)
Employer Health Plan
General Fraud, Errors, and
Abuse
Genetic/DNA Testing
Home Health Care
Hospice

Other Topics Discussed Details:


Yes

Native Hawaiian or Other
Pacific Islander
 White
 Not Collected
Other
Not Collected


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


No

OMB Control Number: 0985-0040 Expire: 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 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.

OMB Control Number: 0985-0040 Expire: Month/Day/2023
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Medicaid
Medical Identity Theft
Medicare Advantage
Medicare Card
Medicare Part A and B
Medicare Part D
Medicare Summary Notice
Medigap or Supplemental
Insurance

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Opioid Fraud and Abuse
SMP Program Information
SMP Volunteer Recruitment
Social Security
TRICARE
Veteran’s Health Benefits
(VA)
Other