State Health Insurance Assistance Program (SHIP) Client Contact Forms

The purpose of this data collection is to collect performance data from grantees, grantee team members and partners. Congress requires this data collection for program monitoring and Government Performance Results Act (GPRA) purposes. This data collection allows ACL and the Center for Innovation and Partnership (CIP) to communicate with Congress and the public on the SHIP, the SMP program, the Medicare Improvements for Patients & Providers Act (MIPPA) program, and the ADRC activities. In addition to the SHIP Data Performance Reports and Information Collection under OMB 0985-0040, ACL requests to incorporate the discontinued SMP Report collection OMB 0985-0024 and the ADRC collection OMB 0985-0062 into one tool. The SHIP, SMP, MIPPA, and ADRC programs are located in each of the 50 states, the District of Columbia, Puerto Rico, Guam and the U.S. Virgin Islands. In order to ensure that grantees report activity accurately and consistently it is imperative that these data collection tools remain active. The respondents for this data collection are grantees, grantee team members, and partners who meet with Medicare beneficiaries and older adults in group settings and in one-on-one sessions to educate them on Medicare enrollment, Medicare benefits and subsidy programs, the importance of being aware of Medicare fraud, error and abuse, and having the knowledge to protect the Medicare system. ACL is proposing to combine these four collection tools to reduce burden on the grantees, grantee team members, and partners as many of the individuals working on these programs, collecting information, and reporting results are the same at the local level. Combining these tools will reduce the need for duplicate or triplicate reporting of activities in separate tools further reducing the time and effort in reporting outcomes and activities. In addition, this combination will allow clarification on when, where, and how activities are being conducted across these ACL programs further informing performance outcomes.

The latest form for State Health Insurance Assistance Program (SHIP) Client Contact Forms expires 2023-12-31 and can be found here.

SHIP/MIPPA Beneficiary Client Form

Federal Enterprise Architecture: Health - Health Care Services

Review document collections for all forms, instructions, and supporting documents - including paper/printable forms.