SHIP Form | Denver Regional Council of Governments

Are you inquiring on behalf of yourself or someone else?

Myself

Someone else

Other…

Name

First

Last

Zip code

ZIP/Postal Code

Age

Ethnicity of the person seeking medicare?

Phone number

How would you prefer to be contacted by a SHIP Counselor?

What is the reason why you are contacting us?

Your name

First

Last

Your phone number

Your email address

Your relationship to the person for whom you're making this inquiry?

Their name

First

Last

Their zip code

ZIP/Postal Code

Their age

Please add any questions you may have.