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Home : SHIC : SHIC intake form SHIC intake form SHIC intake form Please complete the information below. 1. Date 2. First name 3. Last name 4. Phone number 5. Mailing address 6. City 7. ZIP code 8. County 9. Name of Medicare Advantage plan 10. Are you qualified for Medicaid?  Yes  No 11. Do you get medications from the VA?  Yes  No 12. Do you have insurance with TRICARE?  Yes  No 13. Are you insured through an employer or retiree health plan?  Yes  No 14. Are you insured by NDPERS or a federal group?  Yes  No 15. Do you get supplemental security income?  Yes  No 16. Have you qualified for a Medicare Savings Program?  Yes  No 17. Does the county pay for your Medicare premium (QMB, SLMB, QI)?  Yes  No 18. Is single household income less than $16,245 and assets less than $12,640?  Yes  No 19. Is married household income less than $21,885 and assets less than $25,260?  Yes  No 20. Have you been notified by the Social Security Administration that you qualify for low income subsidy?  Yes, full  Yes, partial  Not eligible  Don't know 21. Do you have a yellow drug retrival card from the Insurance Department?  Yes  No 22. If yes, please provide your retrieval code/ID, date/password date and ZIP code. (SEPARATE WITH COMMAS) 23. Are your medications the same as last year?  Yes  No 24. Do you want to select a preferred pharmacy?  Yes  No 25. If you answered "yes" to the previous question, what is the name of your preferred pharmacy and in which city is it located? 26. Medications: include medication name, dosage and vials/pills per month. PLEASE PLACE A COMMA BETWEEN MEDICATIONS, DOSAGES AND VIALS/PILLS PER MONTH. Please end each entry with an asterisk (*).

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