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Print Form Submit by Email OUT11228 OMB No. 0938-0850 NEBRASKA SENIOR HEALTH INSURANCE INFORMATION PROGRAM SHIIP CLIENT CONTACT FORM Section 1 - Client / Counselor Information Client/Representative Name Client Residence Zip Code First Last Counseling Location Zip Code Counselor Name Section 2 - Counseling Session Information Date of Contact First vs.
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How to fill out shiip client contact form
How to fill out SHIIP Client Contact Form
01
Obtain the SHIIP Client Contact Form from the designated source.
02
Fill in the client's full name in the first section.
03
Provide the client's contact information, including phone number and email address.
04
Enter the client's address, including street, city, state, and zip code.
05
Indicate the reason for contacting SHIIP.
06
Select any relevant services the client is interested in.
07
Review all entered information for accuracy.
08
Sign and date the form if required.
09
Submit the completed form as instructed.
Who needs SHIIP Client Contact Form?
01
Individuals seeking assistance with Medicare.
02
Clients looking for information about health insurance options.
03
Seniors needing guidance on benefits enrollment.
04
Caregivers of aging individuals who need health insurance support.
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What is SHIIP Client Contact Form?
The SHIIP Client Contact Form is a document used to gather essential information from clients participating in the State Health Insurance Information Program (SHIIP).
Who is required to file SHIIP Client Contact Form?
Individuals seeking assistance from SHIIP, including seniors and those eligible for Medicare, are required to file the SHIIP Client Contact Form.
How to fill out SHIIP Client Contact Form?
To fill out the SHIIP Client Contact Form, you should provide accurate personal information, including your name, contact details, and any relevant health insurance information as instructed on the form.
What is the purpose of SHIIP Client Contact Form?
The purpose of the SHIIP Client Contact Form is to collect necessary information to assist individuals in navigating their health insurance options and ensuring they receive the support they need.
What information must be reported on SHIIP Client Contact Form?
The information that must be reported on the SHIIP Client Contact Form includes the client's full name, address, phone number, email, date of birth, and details about any existing health insurance plans.
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