SHIIP Disclosure Form

SHIIP counselors operate under a confidentiality agreement. Your information will not be shared or accessed outside of the purpose of a counseling session, and it will be securely stored in your SHIIP file or shredded upon your request.

SHIIP counselors are not licensed insurance agents, and they do not sell or endorse any product, plan, or company. If you have questions about your specific plan, we encourage you to contact your insurance agent or the insurance company.

I understand that the SHIIP counselor (paid staff or volunteer) is acting in good faith to provide information about the Medicare program and about health insurance policies and benefits on a volunteer basis, and that the information shall not be construed as legal advice. *

Yes

The Seniors’ Health Insurance Information Program (SHIIP) uses the Medicare.gov Medicare Plan Finder to compare Medicare Part D and Medicare Advantage health plans.

The Medicare Plan Finder allows for a general comparison or a personalized comparison. A personalized comparison can provide a more accurate comparison but requires an individual to have an online MyMedicare account. With a MyMedicare account you can store your drug list, make updates from year-to-year, and quickly compare drug plans.

To complete a personalized comparison for you, a SHIIP counselor can use your current MyMedicare account user name and password OR help you create a new account. SHIIP can also store your user name and password to be able to assist you in future years.

The account will ONLY be used by SHIIP to access the Medicare.gov website to enter your drugs, store your drug list, and compare drug or health plans for you. At no time will SHIIP access your MyMedicare account without your consent. SHIIP is required to, at a minimum, obtain verbal consent to use your user name and password to access your MyMedicare account or to create an account for you.

If needed I am authorizing SHIIP to assist me in creating an online MyMedicare account, or to access my current account, in order to create or update my drug list and compare Medicare Part D and/or Medicare Advantage plans and I am authorizing SHIIP to securely store the Username for MyMedicare account in order to assist me with plan comparisons or other Medicare enrollment or claims issues now and in the future upon my request. *

Yes

Medicare Beneficiary Name *

Representative Name

Family member, caregiver, etc. on behalf of the Medicare beneficiary

SHIIP Counselor *

Email a receipt

Enter your email address if you would like a copy of this disclosure emailed to you. Otherwise, contact the SHIIP office for a copy.