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Jon Godfread, Commissioner
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Home > SHIC > SHIC Intake
SHIC Intake
SHIC Intake Form
Please complete the information below.
Date
First name
Last name
Phone number
Address
City
ZIP code
County
Name of Medicare Advantage plan
Are you qualified for Medicaid?
Do you get medications from the VA?
Do you have insurance with TRICARE?
Are you insured through an employer or retiree health plan?
Are you insured by NDPERS or a federal group?
Do you get supplemental security income?
Have you qualified for a Medicare Savings Program?
Does the county pay for your Medicare premium (QMB, SLMB, QI)?
Is single household income less than $18,090 and assets less than $13,820?
Is married household income less than $24,360 and assets less than $27,600?
Have you been notified by the Social Security Administration that you qualify for low income subsidy?


Do you have a yellow drug retrieval card from the Insurance Department?
If yes, please provide your retrieval code/ID, date/password date and ZIP code. (separate with commas)
Are your medications the same as last year?
Do you want to select a preferred pharmacy?
If you answered 'yes' to the previous question, what is the name of your preferred pharmacy and in which city is it located?
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 (*).

North Dakota Insurance Department
600 E. Boulevard Ave.
Bismarck, ND 58505-0320
Phone 701.328.2440
Toll free 800.247.0560
Fax 701.328.4880

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