SHIIP PDAP Counseling Tool - Online Submission

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SHIIP PDAP Counseling Tool
LOCAL HELP FOR PEOPLE WITH MEDICARE

Date:

Name:

Age:

Address:

City:

State:

Zip:

Phone: ( ) -

Gender:

Ethnicity: (optional)

Does the client have Medicare? TIP: Must have Medicare to be eligible. If No, STOP HERE. YesNo

Does the client have a Medicare Advantage (+Choice) Plan?
TIP: If the MA Plan offers an exclusive card, the client may only choose one card. If they choose not to get that card, they cannot choose another. If the plan has an exclusive card, STOP HERE.
Plan:
YesNo

Total Montly Income from all sources:

Other Financial Resources
(Stocks, Savings) Exclude house, one car, burial insurance)

Do they have other insurance coverage for prescriptions? (Check all that apply)

                    Medicaid
                    Tricare for Life
                    Federal Employees Health Benefit Plan
                    Other (Retirement, Private; other than Medicare Advantage or Medigap)
                    None
TIP: If a person has outpatient drug coverage from Medicaid, STOP HERE. [S]he is not eligible for the Prescription Drug Discount Card or the $600 credit.

Do they use Indian Health Services? Yes No

Do they use a Long-Term Care Facility Pharmacy? YesNo

                     Client Prefers a Particular Pharmacy? Name:
                     Client prefers a pharmacy with the best price within a 1-10 mile radius
                     Client would consider using generics for additional savings

Name of Drug
(Example: Lipitor)

Strength
(10mg)

Daily Dosage
(Twice Daily)

Results will be completed within one week.

Please select a party to mail to:

Beneficiary
Counselor (for follow-up)

Counselor Name:

Counselor Address:

City:

State:

Zip:



Contact Information:

Vicki Dufrene
Health Care Info-SHIIP
(225) 219-7731
vdufrene@ldi.state.la.us

Date:
Name:
Age:
Address:
City:
State:
Zip:
Phone:	( ) -
Gender:
Ethnicity: (optional)

Does the client have Medicare? TIP: Must have Medicare to be eligible. If No, STOP HERE.	YesNo
Does the client have a Medicare Advantage (+Choice) Plan? TIP: If the MA Plan offers an exclusive card, the client may only choose one card. If they choose not to get that card, they cannot choose another. If the plan has an exclusive card, STOP HERE. Plan:	YesNo
Total Montly Income from all sources:
Other Financial Resources (Stocks, Savings) Exclude house, one car, burial insurance)