State Health Insurance Counseling Intake Questionnaire

Required Fields are marked with an asterisk. *

Date: 10-26-2021

State Health Insurance Counseling (SHIC) Disclosure Statement/Agreement

SHIC Counselors, trained by the North Dakota Insurance Department, are acting in good faith to provide independent, impartial information about health insurance policies and benefits to beneficiaries. Counselors do not sell any type of health care coverage, nor do they endorse or recommend any specific plan or policy. Any information presented by SHIC volunteers or staff should not be construed to be legal advice, and volunteers are not liable for acts and omissions in providing counseling to recipients of service. If you have chosen to make a change to your Medicare Part D plan and are asking SHIC volunteers for assistance to make changes on your behalf, you will be required to give verbal consent acknowledging your request. You will be responsible for the actual plan contract of that enrollment. The SHIC counselor will NOT choose a plan for you.

Applicant Information

Medicare Card Information

Income/Subsidy Information

Application for Extra Help (Low Income Subsidy) with Medicare Prescription Plan Costs.
Medicare Savings Plan.

Drug Plan

Pharmacy Information

Prescription and Pharmacy Information

Provide information about your prescriptions and pharmacy. NOTE: You may be able to obtain a computerized listing from your pharmacist/pharmacy to attach. If not, complete the chart below. Attach additional sheets if needed.
Check this box if you don't take any medication.

Example: Lipitor

Applicant's Agreement, Authorization, and Waiver of Liability

Application for Extra Help (Low Income Subsidy) with Medicare Prescription Plan Costs.
Medicare Prescription Drug Plan Enrollment Form.
My Medicare Account.

I understand the SHIC counselor may assist me with creating a account in order to assist with enrolling into a Prescription Drug Plan, Part D. The information provided for the account is not retained by the counselor . I certify that I provided to the SHIC counselor the information necessary to complete the forms and further certify that the information I provided is true and correct to the best of my knowledge. Counselors do not sell, recommend or endorse any specific insurance product, agent or company nor do they decide which plan is best. I agree that it is my sole responsibility to select the best plan based on the information provided and that I requested enrollment in the selected plan or prefer to enroll myself. Counselors assume no responsibility for decisions made by or actions taken by me. I agree to waive any claims I may have against and hold harmless the (SHIC) Program, the State of North Dakota and the counselor or affiliated agency for any liability arising out of services provided. I agree that I will not hold the SHIC program, the State of North Dakota or its management, employees and volunteers responsible for the denial of benefits or the wrongful receipt of benefits as a result of the health benefit plan chosen by me. I have read this document fully and carefully and I have had the opportunity to ask questions regarding this document. I am voluntarily choosing to sign this document.