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)

1

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:
Phone Number:
Couples X ref#:
Preferred Language:
- Spoken:
- Written:

MBR

English
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:
Phone Number:
Couples X ref#:
Preferred Language:
- Spoken:
- Written:

MBR

English
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:
Phone Number:
Couples X ref#:
Preferred Language:
- Spoken:
- Written:

MBR

English
English

2

Current QDIS display: Applicant Data section (Part D & ‘All’ tab)
Applicant Data
Current Application Status:
Deemed:
Medicare Savings Program (Referral):
Name:
Medicare Claim#:
Title2 Claim#:
SSI Claim#:
RRB Claim#:
Date of Birth:
Sex:
Type of Application:
Contact Type:
Source of Application:
Address:
Source of Address:
Phone Number:
Couples X ref#:
Preferred Language:
- Spoken:
- Written:

Completed - Determined/Done
2019 No
2018 No
2017 No
Yes

Paper
MBR

Other

English
English

Current QDIS display: Spouse Data section (Part D & ‘All’ tab)
Spouse Data
Current Application Status:
Deemed:
Medicare Savings Program (Referral):
Name:
Medicare Claim#:
Title2 Claim#:
SSI Claim#:
RRB Claim#:
Date of Birth:
Sex:
Type of Application:
Contact Type:
Source of Application:
Address:
Source of Address:
Phone Number:
Couples X ref#:
Preferred Language:
- Spoken:
- Written:

Completed - Determined/Done
2019 No
2018 No
2017 No
Yes

Paper
MBR

Other

English
English

3

Change 2:
Current SAAI display

4

Change 3:
Current Appeal Input Screen (APIS)

5

Change 4:
Current Appeals Results Screen (APRS)

6