Form 4 Group Outreach and Education Form

GROUP OUTREACH & EDUCATION FORM OMB No. 0985-0040
* Items marked with asterisk (*) indicate required fields
MIPPA Event *:
 Yes
 No
SIRS eFile ID:
 Yes
 No
Send to SMP:
(*required if sending record to SMP)
Event Details *
Session Conducted By *:
Partner Organization Affiliation* :

Total Time Spent on Event *:
Hours

Title of Interaction *:
Minutes
Type of Event * (select only one):

Number of Attendees *:

Start Date of Activity *:
End Date of Activity:

 Booth/Exhibit

(Health Fair, Senior Fair or Community Event)

 Enrollment

Event

 Interactive

Presentation to Public (In-Person, Video

Conference, Web-based Event, Teleconference)

Event Location *
State of Event * :

Zip Code of Event * :

County of Event * :
Event Contact Information
Event Contact First Name:

Event Contact Phone:

Event Contact Last Name:

Event Contact Email:

Intended Audience * (multiple selections allowed):
 Beneficiaries
 Limited-English Proficiency
 Employer-Related Groups
 Medicare Pre-Enrollees
 Family Members/Caregivers
 Partner Organizations
Target Beneficiary Group * (multiple selections allowed):
 American Indian or Alaskan Native
 Hispanic/Latino
 Asian
 Languages Other Than English
 Black or African American
 Low Income
 Disabled
 Native Hawaiian or other Pacific
Islander
Topics Discussed * (multiple selections allowed):
 Duals Demonstration
 Medicare Fraud and Abuse
 Extra Help/LIS
 Medicare Part D
 General SHIP Program Information
 Medicare Savings Program
 Long-Term Care Insurance
 Medigap or Supplemental Insurance
 Medicaid
 Original Medicare (Parts A and B)
 Medicare Advantage

(Continued on p.2)





People with Disabilities
Rural Beneficiaries
Other





Rural
N/A
Not Collected







Other Prescription Drug Coverage
Partnership Recruitment
Preventive Services
Volunteer Recruitment
Other

Special Use Fields
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Field 2:
Field 3:
Field 4:
Field 5:
Notes