Client Contact Forms
Why Collect Data?
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SHINE is a grant funded federal program
• Requirement of grant that SHINE provide
data to measure performance
• Performance compared nationally
• SHINE funding level based on performance
Why Collect Data, cont.
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Requirement of grant that SHINE conduct targeted
outreach to certain populations and collect data
Targeted SHINE populations:
• General Medicare population
• Populations considered “hard to reach” due to:
Race, culture background, and ethnicity
Limited English proficiency
Dual Eligibles with Mental Illnesses or Disabilities
Beneficiaries with disabilities
Individuals eligible for the low income subsidy for
prescription drug coverage
Client Contact Form (CCF)
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Data collected through Client Contact Forms (CCF’s)
• Collected on paper then entered into computer
system
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CCF must be completed for each contact between
counselor and client
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Client contact= All contacts between a counselor and
a client
• Contacts may be conducted by phone or in person
Completing a Client Contact
Form
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*Asterisk's= Field MUST be filled out
• Grant requirement
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Check all appropriate boxes in each category, many
accept multiple responses

Review each CCF to ensure accuracy prior to
submitting to Regional Director
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Must be submitted MONTHLY
Section 1-3:
Client Identifying Information
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Zip code of Client Residence: Most important information
that MUST be collected
Agency: Where you are counseling
Date of Contact: Date of each contact with a client
• Fill out a separate CCF even if meeting with same client
multiple times
Section 4 & 5:
Information About the Contact
Section 6: Race-Ethnicity &
Language
Section 7 & 8:
Income and Disability Information

Client Monthly Income
• If Below 150% FPL, eligible for LIS

Receiving or Applying for SS Disability
• If under 65 and on Medicare, would always check
YES
Section 9:
Prescription Drug Assistance

Check everything
that you helped the
client with in this
section
Section 10:
Time Spent and Status of Contact

Total Time Spent:
• Includes travel time, time spent preparing for
the appointment, time spent researching
before or after the session
Section 11:
CMS Special Use Fields & Potential Financial
Assistance Provided
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State collects data from this section for state specific reports
MIPPA (Medicare Improvements for Patients and Providers Act): Expectation
is that every counselor screen clients for LIS and MSP
One Care: One Care data entry
Potential Financial Assistance Provided: Provides data showing
how much money SHINE counselors saved beneficiaries by
providing them with information and assistance
• Very important to fill out so accurate beneficiary savings can
be determined
How to Collect Data
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Preferred method= “self-report”
• Self-reporting is the most consistent and valid source of
information
• Client can choose from several categories to describe
themselves

Some clients may be concerned when asked certain
questions they may feel are personal
• Be sensitive to concerns and explain why you are collecting
the data and what is done with it
• Most often, once individuals understand the purpose of the
question, they are happy to cooperate
Race-Ethnicity

Question: Client Race-Ethnicity
• Categories should be read/shown to client for them to
choose applicable category(s)
• Examples of how to ask this question:
 “Which
of the following best represents your racial
or ethnic heritage? Choose all that apply. ”

“Which categories best describes your race or
ethnicity? You can choose one or more categories.”
Primary Language

Question: Client Primary Language Other Than
English
• Primary language refers to the language that a person
acquires in earliest childhood; also, the primary language
of a community
• Also referred to as native language or mother tongue

Examples of how to ask this question:
• “Is English your primary language?”
• “Do you have a primary language other than English?”
Income
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Question: Client Monthly Income
• This question asks whether a clients income is below 150% of
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the Federal Poverty Limit (FPL) or at or above 150% of the FPL
• To avoid making the client reveal their income which may
make some clients uncomfortable, just ask whether income is
below/at or above 150% FPL limit
• SHINE counselors do not need to know a clients exact income
 Counselors responsibility is only to SCREEN for potential
benefit program eligibility
Example of how to ask this question:
• “Is your income below (list the current 150% FPL), or is it at or
above that amount?”
Dual Eligible with Mental
Illness/Disability
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Question: Dual Eligible with Mental Illness/Mental
Disability
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Applicable ONLY for clients on both Medicare and MassHealth
(Dual Eligible)
• If you don’t know if client has MassHealth, ask
• If yes: Ask this question
• If no: Skip this question

Example of how to ask this question:
• “Do you have Medicare and MassHealth and identify as having
a mental illness or a mental disability?”
SHIPtalk
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Website where CCF’s are entered and data collected
All counselors entered into website
• Will receive an email asking to verify your email address, this
will activate your account (must respond w/in 24 hrs)
Another Important feature of SHIPtalk= Used to obtain your CMS
Unique ID
• Unique ID allows you to call CMS Customer Service using the
designated phone number for SHINE counselors
• To receive assistance, must provide your CMS Unique ID
• Will receive email with instructions on how to obtain your
Unique ID