First Name(Or Identifier)Last Namephone # Zip Code of Client

First Name(Or Identifier)Last Namephone # Zip Code of Client

______

First Name(or identifier)Last NamePhone #Zip code of client

______

Counselor NameDate of Contact

Client Contact Information

□ First Contact for issue□ Continuing Contacts for Issue

How did client learn of SHIP/CHOICES?

□ Mailings□ Previous Contact□ CMS/Medicare□ Presentations

□ State Website□ Another Agency□ Friend or Relative□ Media

□ DSS□ OHA□ Access Health CT□ SDA

Method of Contact: (PM)Client Age Group:Client Gender:

□ Phone call □ 64 or younger(PM)□ Female

Face-to-face at location/event site(answer disability question)□ Male

Face-to-face at home/facility□ 65-74

□ Email□ 75-84

□ Postal/Mail□ 85+

Client Race-Ethnicity:Client Primary Language:

□ Hispanic, Latino, or Spanish Origin□ Primary language other than English

□ White, Non-Hispanic□ English is clients primary language

□ Black, African American□ American Indian or Alaska Native

□ Asian Indian□ Chinese□ Filipino□ Japanese

□ Korean□ Vietnamese□ Native Hawaiian□ Guamanian or Chamorro

□ Samoan□ Asian, Other□ Pacific Islander□ Other Race-Ethnicity

Client Monthly Income 150% FPL S:$1507/C$2030)Client Assets (LIS limit: S: $13,820/C: $27,600)

□ Below□ Below

□ At or Above□ At or Above

Receiving/Applying for SSD or Medicare Disability

□ Yes(64 and below)□ No

Prescription Drug Assistance

Medicare Part D:Medicare Advantage Plans

□ 01- Eligibility/Screening□ 27 – Eligibility/Screening

□ 02- Benefit Explanation□ 28 – Benefit Explanation

□ 03 – Plans Comparison□ 29 – Plan Comparison

□ 04 – Plan Enrollment (enter SUF)□ 30 – Plan Enrollment (enter SUF)

□ 05 – Claims/Billing□ 31 – Claims/Billing

□ 06 – Appeals/Grievances□ 32 – Appeals/Grievances

□ 07 – Fraud and Abuse□ 33 – Fraud and Abuse

□ 08 – Marketing/Sales Complaints/Issues□ 34 – Marketing/Sales Complaints/Issues

□ 09 - Quality of Care□ 35 – Quality of Care

□ 10 - Plan Non-Renewal□ 36 – Plan Non-Renewal

Part D Low Income Subsidy (LIS/Extra Help)Medicare Supplemental Plans

□ 11 – Eligibility/Screening□ 37 – Eligibility/Screening

□ 12 – Benefit Explanation□ 38 – Benefit Explanation

□ 13 – Application Assistance (Mark 01 under MIPPA)□ 39 – Plan Comparison

□ 14 – Claims/Billing□ 40 – Claims/Billing

□ 15 – Appeals/Grievances□ 41 – Appeals/Grievances

□ 42 – Fraud and Abuse

Other Prescription Drug Assistance□ 43 – Marketing/Sales Complaints/Issues

□ 16 – Union/Employer Plan□ 44 – Quality of Care

□ 17 – Military Drug Benefits□ 45 – Plan Non-Renewal

□ 18 – Manufacture Programs

□ 19 – State Pharmaceutical Assistance ProgramsMedicaid: - MSP – Mark 02 under MIPPA

□ 20 – Other: specify: ______□ 46 – MSP Screening (QMB, SLMB, ALMB)

□Eligible□ Not Eligible

□ 47 – MSP Application Assistance (You submitted)

Medicare (A and B):□ 48 – Medicaid Screening (all T19 products)

□ 21 – Eligibility Screening□ 49 – Medicaid Application Assistance(You submit)

□ 22 – Benefit Explanation□ 50 – Medicaid/QMB Claims

□ 23 – Claims/Billing□ 51 – Fraud and Abuse

□ 24 – Appeals/Grievances

□ 25 – Fraud and AbuseOther:

□ 26 – Quality of Care□ 52 – Long Term Care Insurance

□ 53 – LTC Partnership

□ 54 – LTC other

□ 55 – Military Health Benefits

□ 56 – Employer/Federal Employee Health

Total Time Spent:□ 57 – COBRA

______Hours ______Minutes □ 58 – Other Health Insurance

□ 59 – Other Specify: ______

MIPPA Special Use Fields (if you completed LIS and/or MSP)

Status:

□ 1 – LIS only □ 2 MSP only □ both LIS and MSP□ General Information/Assistance

□ Detailed Assistance – In progress

PART D ENROLLMENT OUTCOMES:□ Detailed Assistance – Fully Completed

□ Problem Solving – in progress

PDP/MAPD - $ Before:______□ Problem Solving – Fully Completed

PDP/MAPD - $ After: ______

Drug list id:______

Password: ______

PDP/MAPD Notes: ______