SIRS Individual Interaction

INDIVIDUAL INTERACTION: BASIC INTERACTION FORM
* Items marked with asterisk (*) indicate required fields
Type of Interaction*:		Individual Interaction
Session Conducted By*: Date of Interaction (MM/DD/YYYY)*: End Date (if applicable): Date of Initial Creation: Auto-Populated Zip code*: State*: County:					Title of Interaction: Time Spent in Minutes*: Reference Number: Auto-Populated Organization: Auto-Populated
Notes:
Beneficiary Name and Contact Information
Beneficiary First Name: Beneficiary Last Name: Beneficiary Phone: ( ) - - Beneficiary Email:				Beneficiary Address: Beneficiary City: Beneficiary State: Beneficiary Zip Code:
Beneficiary Demographic Information
Race (Multiple selections allowed):		American Indian or Alaskan Native Asian Black or African American Hispanic or Latino				Native Hawaiian or Other Pacific Islander White Not Collected
Gender (Select only one):			Female Male		Other Not Collected
Was Date of Birth Collected?			Yes (MM/DD/YYYY)			No
Beneficiary Age Group:			64 or younger 65-74 75-84			85 or older Not Collected
How Did Beneficiary Learn About SMP:			CMS Outreach Congressional Office Friend/Relative Health/Drug Plan Partner Agency Previous Contact SMP Mailings SMP Media			SMP Presentation SMP Resource Center SSA State Medicaid Agency State SMP Website 1-800-Medicare Other Not Collected
Method of Contact with SMP:			Email Face-to-face at bene home or facility Face-to-face at counseling location or event			Postal Mail/Fax Phone Call Web Based Not Collected

English as Primary Language:		Yes	No
Beneficiary Monthly Income:		At or Above 150% FPL Below 150 % FPL	Not Collected
Medicare Number:
Medicaid Number:
Other Information:
Permission to Contact Beneficiary?		Yes	No
Topic(s) Discussed (education only):
Conditional Payments Consumer Protection Durable Medical Equipment (DME) Employer Health Plan General Fraud, Errors, and Abuse Genetic/DNA Testing Home Health Care Hospice		Medicaid Medical Identity Theft Medicare Advantage Medicare Card Medicare Part A and B Medicare Part D Medicare Summary Notice Medigap or Supplemental Insurance	Opioid Fraud and Abuse SMP Program Information SMP Volunteer Recruitment Social Security TRICARE Veteran’s Health Benefits (VA) Other
Other Topics Discussed Details:

Public Burden Statement:

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless such collection displays a valid OMB control number (OMB 0985-0040). Public reporting burden for this collection of information is estimated to average 5 minutes per response, including time for gathering and maintaining the data needed and completing and reviewing the collection of information. The obligation to respond to this collection is required to retain or maintain benefits.