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VI SHIP Appointment Request Form Complete this form to request a counseling appointment with VI SHIP. Requester Information Are you the beneficiary or requesting on behalf of a beneficiary? * Beneficiary Caregiver/Family Member Other  Requester First Name * Requester Last Name * Primary Phone Number * Please enter a valid phone number. Alternate Phone Number Please enter a valid phone number. Email Address example@example.com Preferred Contact Method * Phone Call Text Message Email Best Time to Contact You * 1 Beneficiary Information Beneficiary First Name * Beneficiary Last Name * Beneficiary Date of Birth * Month Day Year Beneficiary Phone Number * Please enter a valid phone number. Relationship to Beneficiary * Spouse / Partner Adult Child Sibling Legal Guardian / Power of Attorney Professional Caregiver Other  Appointment Details Reason for Appointment * General Medicare Question Medicare Supplement (Medigap) Plan Comparison Medicare Part D Enrollment (Prescription Drug Coverage) Appeals, Grievances, or Billing Issues General Medicare Questions Other  2 Please Select If Other, please specify Preferred Appointment Format * In-Person (St. Croix Office) In-Person (St. Thomas Office) Phone Consultation Preferred Appointment Date * Month Day Year Alternate Appointment Date Month Day Year Additional Information Language assistance needed? * No Yes Language needed Accessibility accommodations required? * No Yes Describe needed accommodations Additional details or questions for the counselor 3 Consent & Acknowledgment TERMS AND ACKNOWLEDGMENT VI SHIP Appointment Request Form Please read the following terms carefully before submitting your appointment request. --- NATURE OF SERVICES The Virgin Islands State Health Insurance Assistance Program (VI SHIP) is a free, unbiased counseling service funded by the Centers for Medicare and Medicaid Services (CMS) and locally administered by the Office of the Lieutenant Governor of the U.S. Virgin Islands. VI SHIP counselors provide information and guidance on Medicare, Medicare Advantage, Medicare Part D prescription drug plans, Medicaid/MAP, and related health insurance topics. VI SHIP services are educational and informational in nature and do not constitute legal, financial, or medical advice. --- NO ENDORSEMENT OR SALES VI SHIP counselors are not affiliated with any insurance company, plan, or product. No counselor will sell, solicit, or enroll you in any plan during your appointment. Any information provided about specific plans is for comparison and educational purposes only. --- APPOINTMENT TERMS By submitting this appointment request form, you acknowledge and agree to the following: 1. Voluntary Participation – Your participation in VI SHIP counseling is entirely voluntary. You may cancel or reschedule your appointment at any time. 2. Accuracy of Information – The information you provide on this form is accurate and complete to the best of your knowledge. Providing false or misleading information may affect the quality of assistance you receive. 3. Appointment Availability – Submission of this form does not guarantee a specific appointment date or time. A VI SHIP representative will contact you to confirm scheduling. 4. No Guarantee of Outcomes – VI SHIP counselors will provide information and guidance based on your individual situation, but cannot guarantee specific enrollment outcomes, plan availability, or coverage results. 5. Timeliness – You understand that Medicare enrollment periods have specific deadlines, and it is your responsibility to act in a timely manner. VI SHIP is not responsible for missed enrollment windows. --- PRIVACY AND CONFIDENTIALITY Any personal information collected on this form, including your name, contact information, Medicare number, and health insurance details, will be used solely for the purpose of scheduling and conducting your counseling appointment. Your information will be kept confidential and will not be shared with third parties, including insurance companies or plan providers, without your explicit consent, except as required by law. --- CONSENT TO BE CONTACTED By submitting this form, you consent to being contacted by VI SHIP staff by phone, email, or mail for the 4 purpose of scheduling, confirming, or following up on your counseling appointment. --- ACKNOWLEDGMENT By signing below, I confirm that:  I have read and understand the terms stated above.  I am requesting a VI SHIP counseling appointment voluntarily.  The information I have provided on this form is true and accurate to the best of my knowledge.  I understand that VI SHIP services are free, unbiased, and do not involve the sale of any insurance product.  I consent to VI SHIP contacting me using the information provided on this form. Date * Month Day Year 5