SHIP Form

Questionnaire to determine if you qualify for LIS (Extra Help)

By completing this form, a Part D personalized comparison listing the three lowest annual cost plans as published on www.medicare.gov will prepared for you by the Northwest Indiana Community Action SHIP Counselors. The State Health Insurance Assistance Program (SHIP) is a program of the State’s Department of Insurance and will provide this information at no cost and does not endorse any of the plans.

Please type your drugs and dosages as they appear on your prescription bottle or package on the chart below. If possible, attach an updated list printed by your pharmacy. Make sure that you spell the name of the drug correctly. Do not include over-the-counter medications such as pain relievers and vitamins.