HMO Recording Script - MA

Pre-Recording explanation

I’ll be conducting a recording as a proof of your HMO registration.

During the recording, I'll be asking your personal information and read the applicable disclosure statements. Please be guided that the only acceptable responses to create a clear and clean recording are direct answers pertaining to the information being asked. If the question is answerable by YES or NO, kindly just respond “YES” if you agree. Otherwise, just respond “NO”. Only the first answer will be considered.

At any point that there is an interruption or background noise in the duration of the recording, I will have to stop and start all over again.

(Discuss the series of information needed and questions to be asked)

Do you have any question or clarification before we conduct the recording?

Recording

Today’s date is MM/DD/YYYY.

Mr. XXX, your answers to the questions that will be asked are provided under penalty of perjury therefore you must provide true and correct answers.

Do I have your permission to record the confirmation of your personal information?

(Customer must say YES)

This is the recording for SafeLink Enrollment ID # XXXXXX.

Could you please confirm your complete name to me?

Could you please confirm your complete address?

Could you please confirm your Date of Birth?

Could you confirm the last four digits of your SSN?

You applied for the service, because you belong to one of these programs: Food stamps, Medicaid, Supplemental Security Income or Temporary Assistance for Needy Families. Is this correct?

(Customer will answer YES or NO)

Great… and the plan assigned is Plan X with X free monthly minutes, correct?

(Customer will answer YES or NO)

Thank you Mr./Mrs. XXX, let me tell you that:

Lifeline is a federal benefit and that willfully making false statements to obtain the benefit can result in fines, imprisonment, de-enrollment or being barred from the program;

Only one Lifeline service is available per household;

A household is defined, for purposes of the Lifeline program, as any individual or group of individuals who live together at the same address and share income and expenses;

A household is not permitted to receive Lifeline benefits from multiple providers;

Violation of the one-per-household limitation constitutes a violation of the Commission’s rules and will result in the subscriber´s de-enrollment from the program; and,

Lifeline is a non-transferable benefit and the subscriber may not transfer his or her benefit to other person.

Mr./Mrs. XXX, now I need you to answer “Yes” or “No” to the following terms and conditions to finish the recording.

Do you certify under penalty of perjury that:

You currently participate in the previously mentioned program.

(Customer will answer YES or NO)

You understand that you must notify SafeLink® within 30 days if:

you no longer participate in the qualifying program

If you or another member of your household obtains Lifeline supported service from another carrier

If you no longer qualify for Lifeline support

or If you change your address

(Customer will answer YES or NO)

Please confirm to your knowledge that:

You understand that your household may receive only one Lifeline supported service. Your Household does not currently receive Lifeline Service OR your household currently receives Lifeline Service from another carrier and you authorize SafeLink to transfer your Lifeline benefit to SafeLink and you understand this will terminate your Lifeline benefits with your existing carrier.

Information in this application is true and accurate

You understand that providing false or fraudulent information to obtain lifeline benefits is punishable by law?

You understand you may be required to recertify the continued eligibility for Lifeline at any time and failure to do so, will result in termination of the Lifeline benefits.

(Customer will answer YES or NO)

You authorize Safelink Wireless or its duly appointed representative to:

Use and disclose my Protected Health Information (PHI) to confirm my initial and ongoing eligibility for Lifeline assistance

Access any records required to verify your statements

Update your address to a proper mailing address format

Provide your name, telephone number, and your address to the Universal Service Administrative Company (USAC) (the administrator of the program) and/or its agents for the purpose of verifying that you do not receive more than one Lifeline benefit.

Authorize social service agency representatives, including the Massachusetts Department of Transitional Assistance, to discuss with and/or provide information to SafeLink Wireless verifying your participation in benefit programs that qualify you for Lifeline assistance.

You are also authorizing your health plan to communicate with you through text messaging programs that provide educational health information and can better assist you in managing your benefits. Messages sent and received are free of charge. You can reply “stop” to any of the messages to opt-out of these services.

(Customer will answer YES or NO)

Can you confirm that you authorize and direct Safelink to activate your handset for you upon shipment?

(Customer will answer YES or NO)

Mr. XXX, thank you, we have finished the recording.

The recording stops HERE