SHIBA Partnership Application

Thanks for your interest in partnering with Solid Ground to run the Statewide Health Insurance Benefits Advisors (SHIBA) program at your organization. Solid Ground’s SHIBA volunteers help people understand their Medicare rights and options. Our well-trained volunteers counsel people of all ages about their Medicare choices – including people under age 65 living with disabilities, people getting ready to turn 65, and those already enrolled.

Currently, our program is primarily done remotely through phone consultations, and we have limited ability to place volunteers onsite for in-person counseling. Because of this, we’ve created this application process to place onsite volunteers at other organizations. We prioritize community organizations that serve people where phone counseling would be an inaccessible service method and/or whose participants are impacted by health disparities and other barriers. Both Solid Ground and our partner organizations agree to run SHIBA collaboratively. SHIBA volunteers who work with your organization will be onboarded as your volunteers. Partner organizations manage the scheduling and oversee SHIBA volunteers while they’re onsite.

Solid Ground works in partnership with the Office of the Insurance Commissioner (OIC) to train, certify, and support SHIBA volunteers on Medicare benefits counseling. If selected, your organization will sign a Memorandum of Understanding (MOU). Fill out the application below to get started!

"*" indicates required fields

Agency Name*

Date*

Address*

Street Address Address Line 2 City State ZIP / Postal Code

Contact Person*

First Last

Phone*

Email*

Website*

Agency Data

In service since:*

Populations served:*

Please describe the community needs your organization meets.*

What’s your tax status?*

(i.e., 501c3, public nonprofit, proprietary health organization, etc.)

Number of your participants who live on low incomes:*

Number of participants w/ Limited English Proficiency (LEP):*

Primary language(s) your participants speak:*

Please describe your programs that specifically serve people who are Medicare eligible, living on low incomes, and/or have LEP.*

Please describe the barriers the people you serve face, if any, in receiving Medicare counseling over the phone.*

Please describe why your organization would like a SHIBA volunteer placed onsite and how it would benefit the community you serve.*

If known, when is the ideal start date and/or reoccurring schedule for a SHIBA volunteer placement at your organization?*

Volunteer Program Information

Please describe your volunteer orientation and training process.*

How do you evaluate your volunteers?*

How do you recognize your volunteers?*

Please list any orientations or trainings a SHIBA volunteer placed at your organization needs to attend before they can begin.*

What areas in King County are available for volunteers to serve in? (If within the city of Seattle, please list the neighborhoods and zip codes.)*

Program Management

Describe how you would promote the SHIBA program to participants.*

Describe how you would train front desk staff and/or volunteers on the SHIBA program and how to take appointments.*

Staff Point-of-Contact for Volunteers*

Please tell us the name, job title, email, and phone number of the staff point-of-contact for volunteers.

First Name Last Name

Title*

Phone*

Email*

Alternate Staff Point-of-Contact for Volunteers*

Please provide the name, job title, email, and phone number of staff responsible if the main point-of-contact is unable to manage appointments (i.e., when they’re out sick or on vacation).

First Name Last Name

Title*

Phone*

Email*

Other Administrative Staff Contacts*

If different from the staff point-of-contact for volunteers and their alternate, please list the names, job titles, emails, and phone numbers of any staff members responsible for taking appointments and making appointment reminder calls to participants.

Partner organizations are required to provide a private space for SHIBA counseling. Does your organization have one?

Yes

If no, please explain.

Please describe the resources and equipment that SHIBA volunteers will have access to at your organization (ex: printer, computer, Wi-Fi, or phone).*

Would you be willing to survey your participants to better understand the outcomes of the SHIBA program service?

Yes

If no, please explain.

If selected as a SHIBA partner, your organization agrees to: 1) share in volunteer supervision while volunteers are onsite, 2) share liability with Solid Ground, 3) manage appointments, and 4) collaborate with SHIBA staff to share relevant information about volunteers placed (i.e., accident reports). Can your organization agree to all of the above?*

Yes

If no, please explain.

SHIBA is a free, unbiased resource. Partners agree to not ask for donations from participants to use the service nor to use SHIBA to refer participants to specific brokers or insurance agents. Does your organization agree to abide by this?*

Yes

If no, please explain.

Do you need training or orientation for your staff about working with volunteers?*

What else should we know about your organization?*

Do you have any questions about SHIBA?*