Texas State Health Insurance Assistance Program (Ship) Client Contact Form printable pdf download

TEXAS STATE HEALTH INSURANCE ASSISTANCE PROGRAM (SHIP) CLIENT CONTACT FORM (_________) 5/01

Counselor Name:

Agency:

Type of Client/Assistance Requested by:

(Check all that apply:

p p p p

Beneficiary (self)

Caregiver (family, other)

Zip Code of Counseling Location:

p p p p

Couple

Agency

Check here for a quick telephone call (less that 10 minutes)

Date of Initial Contact:

Type of Contact:

Time Spent:

p p p p Telephone

p p p p In-person (home)

___/___/____

_______ hours _______minutes

p p p p In-person (site) p p p p e-mail/fax/postal)

Total # of contacts with Client: ______

Total units __________

p p p p Open

p p p p Closed

Status of Client Contact(s):

Section 1 – Beneficiary

Zip Code:

Beneficiary Phone:

Client/Representative Name

Information

(

)

Section 2 - Beneficiary Demographics

p p p p Yes (complete this section) p p p p No (skip to Section 3)

Is this his/her first contact with a SHIP since April 1, 2001?

DOB: ___-___-_____

Gender:

Disabled:

Income:

Ethnicity/Race:

FUnder 65 p p p p Not

p p p p Female

p p p p Yes

p p p p Less than/equal

p p p p Asian

p p p p Amer. Indian/Alaska Native

F65-74

p p p p Male

p p p p No

p p p p White

Collected

to SLMB

F75-84

p p p p Not

p p p p Greater than

p p p p Hispanic

p p p p Hawaiian, other Pacific Isl.

p p p p 85-older

p p p p African Amer. p p p p Not Collected

Collected

SLMB

p p p p Not Collected

p p p p Other_____________________

Section 3 – Topics Discussed (Check all that apply)

Medicare:

Medigap/Sups/Select:

M+C Plans:

Medicaid:

LTC/Other Ins:

p p p p enrollment, benefits,

p p p p Enrollment, eligible,

p p p p Enroll/disenroll

p p p p Medicare Savings

p p p p LTC Ins

eligibility

p p p p Claims/billing

p p p p COBRA

comparisons

eligibility, compare

Program

p p p p

p p p p Appeal/quality care

p p p p Change coverage

p p p p Plan change/non

p p p p Other Health Policy

Nurse Home Medicaid

p p p p Medical Surrogate

p p p p Claims/appeal

F F F F Regular Medicaid

p p p p Ind/group health

renewal

F F F F Appeal

p p p p Claims/appeals

p p p p Non health policy

Decisions

F F F F Other______________

p p p p Fraud/Scams

p p p p Other retirement

p p p p Acute hosp/facility

plan policy _______

o o o o Other____________

_________________

Social Security:

N/C Health:

Individual Rights:

Veterans Issues:

ADLs:

p p p p SSI

p p p p Medications

p p p p Abuse

p p p p Benefits

p p p p Medical Transport.

p p p p Food Stamps- or

p p p p Eyeglasses

p p p p Neglect

p p p p Eligibility

p p p p Community Care

p p p p Dentures

p p p p Exploitation

p p p p Service record

general assistance

for the Aged and

p p p p Disability

p p p p Hearing Aid

p p p p Disable

issues

Disabled

p p p p Benefit/eligibility

p p p p Assist. Device

p p p p Nursing Home

p p p p Other community

discrimination/other

p p p p Appeal

__________________

eligibility (VA)

services__________

Consumer:

Other Issues:

Housing :

p p p p Collections

p p p p Money Management.

o o o o Federal, state, local

p p p p Dispute/landlord/tenant p p p p Alternative

p p p p Fraud/Scams

p p p p Guardianship

p p p p Repair/modification

county, city, rail-

housing

p p p p Bankruptcy

p p p p Probate matters

p p p p Utilities/weatherization

road, teacher, or

p p p p Financial counsel.

p p p p Other Surrogate

p p p p Eviction/relocation

cooperate retire-

p p p p Bill reduction

p p p p Property tax

issues

ment plans (circle

p p p p Rent Subsidy

one)

Texas State Health Insurance Assistance Program (Ship) Client Contact Form

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