SHIIP Client Contact Form

To electronically submit your updated contact information for a SHIIP Client Contact to the Louisiana Department of Insurance, please fill out the form below and click submit.

State Health Insurance Assistance Program (SHIP) Client Contact Form
Counselor Name: Counseling Zip Code/Location:	Type of Client/Assistance Requested by: (check all that apply) Beneficiary (self) Caregiver (family member, conservator) Couple                          Agency
How Did the Client Learn About the SHIIP? 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:  (mm/dd/yy)	Type of Contact: Quick Call (<10 min) Telephone        In-Person (home visit)  In-Person (site) Email/Fax/PostalMail	Time Spent: Hours Minutes
Date of Mulitiple Contact: (mm/dd/yy)	Type of Contact: Quick Call (<10 min) Telephone        In-Person (home visit)  In-Person (site) Email/Fax/PostalMail	Time Spent: Hours Minutes
SECTION 1 - BENEFICIARY INFORMATION
Beneficiary Information First Name:  Last Name:   Zip Code: Phone Number: ( ) - Representative Information First Name:   Last Name:
SECTION 2 - BENEFICIARY DEMOGRAPHICS (RECOMMENDED) Is this his/her first contact with a SHIP since April 1, 2001? (If Yes, Complete this section. If No, Skip to Section 3)
Age Date of Birth: (mm/dd/yy) OR under 65 65 - 74 75 - 84   85 or older Not Collected Monthly Income Below 150% of FPL         At or greater than 150% of FPL Not Collected $ Ethnicity/Race: American Indian or Alaska Native Asian Black or African American Hispanic or Latino Native Hawaiian/Other Pacific Islander White Other:  Not Collected Gender Female Male Not Collected Disabled Yes No Not Collected
SECTION 3 - TOPICS DISCUSSED (Check all that apply)
Prescrition Assistance Medicare Prescription Drug Coverage (PDP/MA-PD): Plan eligibility, benefit comparisons Low-income assistance - eligibility, benefit 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  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 Plan or benefit changes/non-renewals Claims/billing Appeals/quality of care/complaints Medicaid (e nrollment, eligibility, benefits): QMB/SLMB/QI Other Medicaid Medigap/Supplement/SELECT: Enrollment, eligibility, comparisions Change coverage Claims/appeals Other: Long-Term Care Fraud and Abuse Military Health Benefits Employer Health Plan or Federal Customer Service issues/complaints Other Dollar Amount Saved: $