SHINE - Serving Health Insurance Needs of Elders


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SHINE
1-800-96-ELDER
(1-800-963-5337)

Sunshine For Seniors Prescription Assistance Intake
*This form is for SHINE / Sunshine for Seniors volunteers' use only.*
(Fields required are marked with *)
Counselor's Information:
Counselor's Name:
County:
PSA:
*Email:
Client's Information:
*Client's Name:
Mailing Address:
City:
County:
Zip:
Please check the item(s) that applies HIPPA Notification: Made Sent Sunshine for Seniors Brochure Sent for Subsequent Follow-Up Client Referred to PAP Websites for Independent Search Referred to Manufacturer's Retail Discount Program PAP Applications Sent
Estimated potential total monthly savings:	dollars
Date (mm/dd/yyyy):
Total Time Spent:	hours
(To the nearest quarter hour - .25 for a quarter, and include all time spent on SfS client counseling and follow-up activities.)