______
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: ______