SHICK TR/MOU Form

SHICK Counselor Training Record

Annual Training Record/Confidentiality Agreement/Memorandum of Understanding

Most SHICK information and correspondence is sent via email. An email address is REQUIRED.

Required fields are marked with an *.

Please select your Training Date

First name*

Middle name

Last Name*

Nickname

Address *

City*

State*

Zip code*

County*

Email*

Phone*

Secondary phone or Extension

We will only use your personal information to contact you with requests or information you'll need as a SHICK volunteer. We won't share your contact information outside the SHICK program without your permission, unless we're obligated by law to disclose it.

CONFIDENTIALITY AGREEMENT FOR RECEIPT OF 1-800 MEDICARE UNIQUE ID

Confidentiality Agreement*

I hereby agree and understand that I am accountable in protection of the privacy and confidentiality of the information that is disclosed to me pursuant to my use of the Unique ID which has been created to be used by the Centers for Medicare & Medicaid Services. This ID, along with other identifying information will allow a 1-800-MEDICARE Customer Service Representative (CSR) or participating Medicare Advantage or Part D Plan sponsor to disclose certain beneficiary eligibility and claims payment-specific information to me for the purpose of assisting the beneficiary. I further understand this Unique ID is to be confidential and I am not to disclose this ID to anyone other than the CSR.

Choose your response

I am requesting a Unique ID number be assigned to me.
I already have a Unique ID number.
I do not want a Unique ID number to be assigned to me.

Please read the Confidentiality Agreement and sign it by entering your name and the date.*

By entering your name in this box, you are agreeing to the terms of the CONFIDENTIALITY AGREEMENT FOR RECEIPT OF 1-800 MEDICARE UNIQUE ID.

Confidentiality Agreement Signature

Please enter your full name

Confidentiality Agreement Date

mm/dd/yyy

Unique ID Number Assignment SHIP Signature - Office Use Only

Newly Assigned CMS Unique ID Number - Office Use Only

Memorandum of Understanding

MEMORANDUM OF UNDERSTANDING - REGARDING COUNSELOR RESPONSIBILITIES AND OBLIGATIONS (Please check all boxes)*

As a certified Counselor in the Senior Health Insurance Counseling for Kansas Program, I agree to follow all program guidelines and regulations. Neither the Senior Health Insurance Counseling for Kansas Program nor the Sponsoring Organization is responsible for my activities or responsibilities other than those stated in these program guidelines. Any action beyond those covered in the guidelines will be taken at my personal risk.

1. NATURE OF SERVICE

I understand that my basic responsibilities as a Counselor include providing accurate, objective, unbiased counseling and assistance with Medicare, health insurance, and related health coverage plans for Medicare beneficiaries, their representatives or persons soon to be eligible for Medicare, and educating the public on Medicare and health insurance issues that affect older citizens. I agree to take the Initial Training Certification and/or participate in Update Training as required under this program. I understand that I may conduct counseling sessions at specified counseling sites, by telephone, or at clients’ homes if their health conditions require. I agree to complete the Client Contact Forms and to submit them each month.

2. CONFIDENTIALITY

It is understood that in the performance of my duties, I will have access to certain sensitive information about the client, and that such information may include medical, insurance, financial and other personal and confidential data. I agree to restrict my use of such information to the performance of my counseling duties described in the program guidelines and understand that there is to be no discussion of cases or mentioning of clients’ names except when in direct contact with Medicare, insurance companies, providers of medical services/supplies, and/or members of the Senior Health Insurance Counseling for Kansas program staff.

3. CONFLICT OF INTEREST

The Senior Health Insurance Counseling for Kansas Program requires that counselors shall not promote private or personal interests in conjunction with the performance of duties covered in the state program guidelines. To comply with these requirements, I agree to the following: 1. I will in no way attempt to conduct market research or solicit, persuade, or coerce clients to purchase a specific type of medical insurance coverage, to convert an existing policy to another carrier, to go to a specific provider of service for treatment, or to direct a client to a specific agent/broker or any profit-based billing service. I understand that this means that neither I nor a member of my immediate family may be currently in the business of health insurance. 2. I will not disclose nor use confidential information obtained as a result of my association with or access to any client for personal gain or advantage for my employer or any other parties.

4. COMPLIANCE

I acknowledge that I am aware of all volunteer policies as listed in the SHICK Volunteer Risk & Program Management Policies, VRPM policy 1.3.

5. ACKNOWLEDGMENT

I hereby acknowledge my obligation to respect the confidentiality of the client and to exercise good faith and integrity in all dealings with the client in the performance of my duties as a Certified Counselor in the Senior Health Insurance Counseling for Kansas program. I have received training in privacy issues and protecting client confidentiality as well as the use of the SHIP Unique ID. I understand that a breach of confidentiality or conflict of interest will make me personally liable for my actions regarding the client’s right to privacy and confidentiality, and could be grounds for de-certification as a Counselor.

Please read the Memorandum of Understanding and sign it by entering your name and the date.

MOU Signature

Enter full name as signature

MOU Date

mm/dd/yyy

Privacy & Confidentiality Quiz - Answers to all questions are required for Update training.

Question 1 - Which of the following are true? State privacy protection laws _____.

A. Apply to individuals and organizations, including nonprofit organizations
B. Define personal protected information (PPI)
C.Are subject to change at any time without prior notification.
D. A and B

Question 2 - Volunteers and counselors must be trained annually on confidentiality.

A. True
B. False

Question 3 - SHICK counselors have access to beneficiary’s health and other forms of personal identifying information. Why is confidentiality so important?

A. It builds the program’s reputation as a trusted and reliable resource.
B. It demonstrates respect.
C. It helps prevent costly privacy and security breaches.
D. All of the above

Question 4 - VRPM stands for The SHIP and SMP Volunteer Risk Metrics.

A. True
B. False

Question 5 - Strong passwords should include which of the following?

A. The name of a pet
B. Your first or last name
C. Your favorite sports team
D. None of the above

Question 6 - When using wi-fi networks it is best practice to ensure which of the following?

A. To always use secured networks
B. That the wi-fi does not require a password to access
C. Ensuring that HTTPS is in the website URL
D. A & C

Question 7 - Which of the following would not be considered a conflict of interest?

A. Being a licensed insurance agent or representative
B. Counseling a friend or family member
C. Selling copies of your bands’ CD to each customer
D. Sending beneficiaries to one specific agent or agency after each appointment

Question 8 - You should Store PPI in password-protected files on password-protected computers that only authorized users can access

A. True
B. False

Question 9 - HIPPAs’ privacy rule does not apply to which of the following?

A. Conversations that a person might have about a patient or client
B. Paper left on a desk or copy machine that includes PHI
C. Employment records, including medical information
D. Things that could be overheard

Question 10 - HIPPA covered entities can disclose health information for public interest and benefit activities during a national health emergency.

A. True
B. False

Long Term Services & Supports

SHICK Counselor Training Record

CONFIDENTIALITY AGREEMENT FOR RECEIPT OF 1-800 MEDICARE UNIQUE ID

Memorandum of Understanding

Privacy & Confidentiality Quiz - Answers to all questions are required for Update training.