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SHIBA Contact Form
Michael Mosin
2021-09-29T13:35:21-07:00
SHIBA Contact Request
Submit a request for a SHIBA member to contact you.
Reason for Contact
(Required)
Please SELECT ONE (1) of the options from the dropdown menu.
REQUEST - SHIBA Appointment for SELF
REQUEST - SHIBA Appointment for SELF & SPOUSE
REQUEST - SHIBA Appointment for SOMEONE ELSE
INQUIRY - Volunteering with SHIBA
INQUIRY - SHIBA Events
OTHER / UNSURE
Name
(Required)
Please enter your FULL NAME (first & last) by which you prefer to be addressed.
First Name
Last Name
Residence
(Required)
Please enter the CITY and ZIP CODE associated with your / the beneficiary's residential address.
City
ZIP Code
Preferred Contact Method
(Required)
Please SELECT ONE (1) of the options listed below:
PHONE CALL
EMAIL
EITHER (Call or Email)
Email
Please enter the email address you would prefer us to contact you or send materials.
Enter Email
Confirm Email
Phone
Please enter the PHONE NUMBER you prefer for us to call to reach you.
When we call, can we leave a voice message?
If "YES", please make sure the voicemail inbox is properly set up & empty enough to receive new messages.
YES
NO
Does the the Medicare beneficiary have a Medicare.gov Account set up?
It is highly recommended for eligible Medicare beneficiaries to have a Medicare.gov account, as it is very helpful & saves time for both the beneficiaries & the advisors.
YES - I know how to access / use it
YES - I need help accessing / using it
NO - I'll make one before the SHIBA appointment
NO - I need help making one
I'M NOT SURE...
NOT APPLICABLE
Race / Ethnicity
Please SELECT ONE (1) of the options from the dropdown menu.
American Indian or Alaskan Native
Asian
Black or African American
Hispanic or Latino
Native Hawaiian or Other Pacific Islander
White
NO SELECTION (will provide during conversation with SHIBA volunteer)
Additional Notes & Details
Please provide any additional relevant information or briefly summarize your needs. (Maximum 300 characters)
Comments
This field is for validation purposes and should be left unchanged.
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