State Health Insurance Counseling (SHIC) Intake Questionnaire

North Dakota Insurance Department
SFN 61886

1Applicant Information > 2Medicare > 3Prescription and Pharmacy > 4Ageement/Authorization/Waiver
MEDICARE OPEN ENROLLMENT is October 15th to December 7th
STATE HEALTH INSURANCE COUNSELING (SHIC) DISCLOSURE STATEMENT/AGREEMENT
SHIC Counselors, trained by the North Dakota Insurance Department, are acting in good faith to provide independent, impartial information about health insurance policies and benefits to beneficiaries. Counselors do not sell any type of health care coverage, nor do they endorse or recommend any specific plan or policy. Any information presented by SHIC volunteers or staff should not be construed to be legal advice, and volunteers are not liable for acts and omissions in providing counseling to recipients of service. If you have chosen to make a change to your Medicare Part D plan and are asking SHIC volunteers for assistance to make changes on your behalf, you will be required to give verbal consent acknowledging your request. You will be responsible for the actual plan contract of that enrollment. The SHIC counselor will NOT choose a plan for you.
Who is completing the form?
Applicant Counselor
Name of SHIC Counselor *
- Applicant Signature *
- Date *
- Applicant's Representative Signature (if applicable)
- Date
APPLICANT INFORMATION
- Applicant Last Name *
  Maximum of 50 characters allowed. Currently Entered: 0 characters.
- Applicant First Name *
  Maximum of 50 characters allowed. Currently Entered: 0 characters.
- Date of Birth *
- Address *
  Maximum of 100 characters allowed. Currently Entered: 0 characters.
- City *
  Maximum of 100 characters allowed. Currently Entered: 0 characters.
- State *
  Must be 2 characters. Currently Entered: 0 characters.
- ZIP Code *
  Must be between 5 and 10 characters. Currently Entered: 0 characters.
- Telephone Number * - ### - ### ####
- County *
  Maximum of 100 characters allowed. Currently Entered: 0 characters.
- Email Address *
  Maximum of 100 characters allowed. Currently Entered: 0 characters.
- How did you hear about SHIC? *
- Primary Language Spoken *
- I am interested in reviewing my Part D Drug Plan:
  Yes No
- I am interested in reviewing my Advantage Plan:
  Yes No
- Do you currently have other insurance coverage?
  Yes No
- Specify Insurance Company

State Health Insurance Counseling (SHIC) Intake Questionnaire

State Health Insurance Counseling (SHIC) Intake Questionnaire

MEDICARE OPEN ENROLLMENT is October 15th to December 7th

STATE HEALTH INSURANCE COUNSELING (SHIC) DISCLOSURE STATEMENT/AGREEMENT

APPLICANT INFORMATION