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BENEFICIARY CONTACT FORM

* Items marked with asterisk (*) indicate required fields

Date of Contact *: Date of Initial Creation: {Auto Populated}

Record Last Updated By:{Auto Populated} Date of Last Update: {Auto Populated}

MIPPA Contact *:

Yes

No

Send to SMP:

Yes

No

SIRS Reference Number: {Auto Populated}

SHIP Reference Number: {Auto Populated}

Counselor Information *

Session Conducted By*: Auto Populated Partner Organization Affiliation*: Auto Populated

ZIP Code of Session Location *: ___________________________

State of Session Location *: __________________

County of Session Location *: _____________________________________________________

Beneficiary & Representative Name and Contact Information

Beneficiary First Name: ______________________________ Beneficiary Last Name: ______________________________ Beneficiary Phone: (______) -__________ -____________ Beneficiary Email: ___________________________________

Representative First Name: _____________________________ Representative Last Name: _____________________________ Representative Phone: (______) -__________ -____________ Representative Email: ___________________________________

Beneficiary Residence *

State of Bene Res. *: ________

Zip Code of Bene Res. *: ________

County of Bene Res. *: _________________________

How Did Beneficiary Learn About SHIP * (select only one):

CMS Outreach Congressional Office Employer Friend or Relative Health/Drug Plan Partner Agency

Previous Contact SHIP Mailings SHIP Media SHIP Presentation State SHIP Website

SHIP TA Center SSA State Medicaid Agency 1-800 Medicare

Other Not Collected

Method of Contact * (select only one):

Beneficiary Age Group * (select only one):

Phone Call Email Web-based Postal Mail or Fax

Face to Face at Session Location/ Event Site

Face to Face at Bene Home/ Facility

64 or Younger 65 – 74 75 – 84

85 or Older Not Collected

Beneficiary Race * (multiple selections allowed):

Beneficiary Language *:

American Indian or Alaska Native Asian Black or African American Hispanic or Latino

Native Hawaiian or Other Pacific Islander White Not Collected

English is Beneficiary’s Primary Language

Yes

No

Receiving or Applying for Social Security Disability or Medicare Disability * (select only one):

Yes

No

Have you or a family member ever served in the military?

Yes

No

Unsure

Beneficiary Monthly Income * (select only one):

Beneficiary Assets * (select only one):

Below 150% FPL At or Above 150% FPL

Not Collected

Below LIS Asset Limits Above LIS Asset Limits

Not Collected

Which of the following best represents how you think of yourself? * (Select only one):

Lesbian or gay Straight, that is, not gay or lesbian Bisexual

I use a different term ________________________________ Don’t know Prefer not to answer

What is your current gender? * (select only one):

Do you consider yourself transgender? * (select only one)

Female Male Transgender

I use a different term ________________________ Don’t know Prefer not to answer

Yes Prefer not to answer

No

Topics Discussed * (At least one Topic Discussed selection is required. Multiple selections allowed)
Original Medicare (Parts A & B) Medigap and Medicare Select Medicare Advantage (MA and MA-PD)	Accountable Care Organizations (ACOs) Appeals/Grievances Benefit Explanation Claims/Billing Conditional Enrollment Coordination of Benefits Eligibility Enrollment/Disenrollment Equitable Relief Fraud and Abuse Late Enrollment Penalty Provider Participation QIO/Quality of Care Application Assistance Benefit Explanation Claims/Billing Complaints Eligibility/Screening Fraud and Abuse Guaranteed Issue Rights Plan Non-Renewal Plans Comparison Appeals/Grievances Benefit Explanation Chronic Condition Special Needs Plans Claims/Billing 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 Part D Low Income Subsidy (LIS/Extra Help) Other Prescription Assistance Other Insurance	Appeals/Grievances Benefit Explanation Claims/Billing Disenrollment Eligibility/Screening Enrollment Fraud and Abuse Late Enrollment Penalty Marketing/Sales Complaints & Issues Pharmacy Network Plan Non-Renewal Plans Comparison Appeals/Grievances Application Assistance Application Submission Benefit Explanation Claims/Billing Eligibility/Screening LI NET/BAE Manufacturer Programs Military Drug Benefits Prescription Discount Cards State Pharmaceutical Assistance Programs Union/Employer Plan 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
Topics Discussed (cont’d) * (At least one Topic Discussed selection is required. Multiple selections allowed)
Medicaid	Appeals/Grievances Benefit Explanation Claims/Billing Duals Demonstration Eligibility/Screening Fraud and Abuse Medicaid Application Assistance Medicaid Application Submission Medicare Buy-In Coordination Medicaid Expansion (ACA) Transition to Medicare Medicaid Managed Care Medicaid Recertification Medicare Buy-in Coordination 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		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 Mental Health Medicare.gov Account New to Medicare Opioids Physical Therapy Preventive Benefits Skilled Nursing Facility Substance Misuse/Fraud Telehealth Transportation
Total Time Spent on This Contact *		Status
____ Hours _______Minutes		In Progress			Completed
Special Use Fields
Original PDP/MA-PD Cost: _______________ New PDP/MA-PD Cost: _______________		Field 3: _______________ Field 4: _______________ Field 5: _______________ Field 6: _______________ Field 7: _______________ Field 8: _______________
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 is estimated to average 5 minutes per response, including time for gathering and maintaining the data needed and completing and reviewing the collection of information. The obligation to respond to this collection is required to retain or maintain benefits.

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