HomeMy WebLinkAbout0015_SHIIP_Client_NoticeSHIIP Form #0015
SHIIP—SMP is sponsored by the State of Iowa Insurance Division to make information on Medicare
and health insurance more widely available and understandable to Iowans on Medicare and to assist
with Medicare fraud and abuse cases. Services are provided by trained volunteer counselors who are
not actively affiliated with the insurance, financial planning or pharmaceutical industries.
SHIIP—SMP and its volunteers do:
Give you helpful information on how you can compare Medicare and health insurance plans.
Give you information and assistance to make Medicare & health insurance decisions easier.
Upon request, assist with applications for, and enrollment in Medicare prescription drug plans, health
plans and assistance programs.
Keep all information confidential.
Assist with Medicare health insurance problems and Medicare fraud & abuse.
SHIIP—SMP and its volunteers do NOT:
Advise you on the purchase, renewal or termination of specific insurance products.
Provide legal advice.
Make decisions for you.
Endorse or recommend any particular insurance product, agent, company, Medicare Advantage
or prescription drug plan.
SHIIP—SMP, its volunteers and sponsors are NOT liable for decisions you make based on
information or assistance provided. Health insurance often involves the most important and costly
decisions that you can make. You may need to talk to an attorney, accountant, government office,
public service agency or other resource before making such a decision.
I understand that my counseling records may be shared between SHIIP—SMP counselors who serve
me.
Should you have any complaints or suggestions for making SHIIP—SMP more responsive to your
needs, please let us know by calling (800) 351-4664. The Iowa Insurance Division may contact you
at a later date to assess your satisfaction with the service provided by the SHIIP—SMP program.
Beneficiary Name (Print) Beneficiary/Representative Signature Date
AUTHORIZATION to RELEASE INFORMATION
I authorize ___________________________________________(SHIIP—SMP Counselor) to share
with, or collect from, Medicare, Social Security, Iowa Department of Human Services, insurance
companies, agents, pharmacies, providers and appropriate enforcement agencies information
pertaining to the above named beneficiary’s Medicare and/or health insurance coverage. I
understand that the information supplied will be held in trust and used only in ways authorized by the
beneficiary or designated representative. This authorization remains valid for 12 months from the
date of signature unless earlier revoked in writing.
_________________________________________ ___________________
Beneficiary or Representative Signature Date
Notice to SHIIP—SMP Client