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OMB No. 0938-0850

State Health Insurance Assistance Program (SHIP)

Virginia Insurance Counseling and Assistance Program (VICAP)

Client Contact Form

Counselor Name:

Counseling Location Zip Code:

     __ __ __ __ __

Type of Client/Assistance Requested by:  (check all that apply)

Beneficiary (self)

Couple

Caregiver (family member, conservator)

Agency

How Did Client Learn About the SHIP:  (check one)

CMS (1-800-Medicare, www.Medicare.gov, Medicare & You, CMS mailing)

Presentations/Fairs

State-specific mailings/brochures/ posters

Agency (senior org, disability org, Social Security)

Friend/Relative

Media (PSA, ad, newspaper, radio, etc.)

Other: ______________________

Not Collected

Date of Initial Contact:

__ __ / __ __ / __ __ __ __ month /    day    /         year

Type of Contact:

Quick call (<10 min)

Telephone

In-Person (site)

In-Person (home visit)

E-mail/fax/postal mail

Time Spent:

      _________ hours     _________ minutes

Date if Multiple Contact:

__ __ / __ __ / __ __ __ __

month /    day    /         year

Type of Contact:

Quick call (<10 min)

Telephone

In-Person (site)

In-Person (home visit)

E-mail/fax/postal mail

Time Spent:

      _________ hours     _________ minutes

SECTION 1 – BENEFICIARY INFORMATION

Beneficiary Name:

     ____________________      ____________________

                       First                                                    Last

Beneficiary Zip Code:

     __ __ __ __ __

Representative Name (if applicable):

     ____________________      ____________________

                       First                                                    Last

Beneficiary Telephone #:

     ( __ __ __ )  __ __ __ - __ __ __ __

SECTION 2 – BENEFICIARY DEMOGRAPHICS  Is this his/her first contact with a SHIP since April 1?         YesNo

                                                                                                    (If Yes, Complete this section.  If No, Skip to Section 3)  

 Age:

  Date of Birth: __ __ / __ __ / __ __ __ __  OR

                       month /  day   /       year

Under 50 years

60 - 64

75 – 84

50 - 59

65 – 74

85 and older

Not Collected

Gender:

 Female

 Male

 Not Collected

Monthly Income:

Below 150% of FPL

At or greater than 150% of FPL

Not Collected

      $_____________

Disabled:

 Yes

 No

 Not Collected

Race/Ethnicity:

American Indian or Alaska Native

Asian

Black or African American

Hispanic or Latino

Native Hawaiian or other Pacific Islander

White, Not of Hispanic origin

Other

Not Collected

SECTION 3 – TOPICS DISCUSSED (check all that apply)

Medicare (Parts A and B):

Enrollment, eligibility, benefits

Claims/billing

Appeals/quality of care/complaints

Medicare Health Plans (HMOs, PPOs, PFFS, Special Needs Plans):

Enrollment, disenrollment, eligibility, comparisons

Plan or benefit changes/non-renewals

Claims/billing

Appeals/quality of care/complaints

Medicaid (enrollment, eligibility, benefits):

QMB/SLMB/QI

Other Medicaid

Medigap/Supplement/SELECT:

Enrollment, eligibility, comparisons

Change coverage

Claims/appeals

Other:

Long-Term Care

Fraud and Abuse

Military Health Benefits

Employer Health Plan or Federal Employee Health Benefits Program

Customer Service issues/complaints

Other:  _________________

Prescription Assistance:

Medicare Prescription Drug Coverage (PDP/MA-PD):

Plan eligibility, benefit comparisons

Low-income assistance - eligibility, benefit comparisons

Enrollment / application assistance

Claims / billing

Appeals/quality of care/complaints

Other Sources of Prescription Drug Coverage/Assistance:

Medicare-Approved Drug Discount Card

State Pharmacy Assistance Program

Union/Employer plan

Manufacturer’s Assistance Program

Discount plans

Other:  ______________________

Form CMS-_________ (07/05)

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