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805-654-3200
ATTENTION: KNOW YOUR RIGHTS!
If you speak another language, language assistance services, free of charge, are available to you. Call TTY: 1-800-735-2922 or 711
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Test Comparison-Appointment Request Form
Name
*
First
M.I.
Last
Address
*
Street Address
Address Line 2
City
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Mailing address different from above?
*
No
Yes
Mailing Address
Street Address
Address Line 2
City
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Birthdate
*
MM slash DD slash YYYY
Phone
*
Email
*
Preferred method of contact for appointment:
*
Email
Telephone
Online zoom
In person
What is the best time to reach you?
*
:
Hours
Minutes
AM
PM
AM/PM
Preferred language?
*
English
Spanish
Other
Please specify
SOCIAL HISTORY
Marital Status:
*
Married
Separated
Domestic Partner
Never Married
Divorced
Widowed
Decline to state
Race
*
African American / Black
American Indian / Alaskan Indian
Caucasian / White (Not Hispanic)
Asian Indian
Cambodian
Chinese
Filipino
Guamanian
Hawaiian
Japanese
Laotian
Samoan
Vietnamese
Not Collected
Decline to state
Two or More Races
Other
Ethnicity
*
Hispanic / Latino
Not Hispanic / Latino
Not Collected
Decline to state
The Gay Bisexual and Transgender Disparities Reduction Act of 2016 (AB 959)
What is your gender?
*
Male
Female
Transgender Female to Male
Transgender Male to Female
Genderqueer / Non-binary
Decline to state
Missing / Not Collected
Not listed, please specify
Specify
What was your sex at birth?
*
Male
Female
Decline to state
Missing / Not Collected
How do you describe your sexual orientation or sexual identity?
*
Straight / Heterosexual
Bisexual
Gay / Lesbian
Questioning / Unsure
Decline to state
Missing / Not Collected
Not listed, please specify
Specify
Please look at your prescription drug card / health plan card and look for PDP or HMO
Do you have a Stand Alone Part D Plan (PDP)?
*
No
Yes
Please specify name of plan
Specify preferred pharmacy
Do you have an HMO Medicare Advantage?
*
No
Yes
Please specify name of plan
Specify preferred pharmacy
Do you receive prescription drug coverage from a retiree, union or employer plan?
*
No
Yes
Are you entitled to Veteran's Health Benefits (VA or TRICARE for Life)?
*
No
Yes
You may be eligible to save on prescription drug costs & qualify for other programs.
Are you on Medi-Cal?
*
No
Yes
What is your share-of-cost (SOC) amount?
*
Interested in applying?
*
No
Yes
Your ASSETS (Bank and IRA Accounts) are LESS than $15,510 if Single or $30,950 if Married:
*
No
Yes
Your MONTHLY GROSS INCOME is LESS than $1,719 if Single or $2,309 if Married
*
No
Yes
Name of Drug / Dosage / How Often
The information you provide will guide our comparison.
TIP:
Pull out your medication bottles and transcribe full drug name into the field below. Click on the plus sign to add more fields.
If you MUST have a BRAND, check YES
*
No
Yes
Please list name of drug / Dosage (how many mg) / How often (#per day/week/mo/yr)
*
Name of Drug
Dosage (how many mg)
How Often (# per day/week/mo/yr)
How did you hear about us?
*
Another Agency (SSA, Medi-Cal, etc.)
Aging into Medicare Booklet
California Department on Aging
California Health Advocates
Centers for Medicaid and Medicare Services
Friend/Relative
Info-Van
Internet
Mailing
Media
Outreach Event by HICAP
Other
Please specify:
*
DISCLOSURE STATEMENT
HICAP counseling services are provided by trained counselors, registered by the California Department of Aging, who are acting in good faith to provide independent, impartial information about health insurance policies and benefits to clients. Counselors do not sell any type of health care coverage. They do not endorse or recommend any specific plan or policy. Information presented by HICAP volunteers should not be construed to be legal advice, and volunteers are not liable for acts and omissions in providing counseling to recipients of service.
Welfare and Institutions Code, Section 9541 (1)(4)
By entering your name and date below, you acknowledge that you have read and understand this disclosure.
*
Date
*
MM slash DD slash YYYY
© 2023 • Ventura County Area Agency on Aging
