Interest Form

1
What is your name?* This field is required.The name of the person submitting the form or the name of the person we should contact
2
If you are a caregiver or loved one, what is the name of the person experiencing memory issues? (please enter name as it appears on insurance card)
3
In what state is the location of care for the person experiencing memory issues?* This field is required.
Please Select
Please Select
AL
AK
AR
AZ
CA
CO
CT
DC
DE
FL
GA
HI
ID
IL
IN
IA
KS
KY
LA
ME
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VT
VA
WA
WV
WI
WY
4
Is Traditional Medicare (Parts A & B) the primary insurance for the person experiencing memory issues?* This field is required.
Yes
No
Not sure
5
If the person to receive care has this red, white, and blue card from Traditional Medicare, the answer to the prior question should be "Yes". Medicare Advantage beneficiaries get a different card. If sure about your answer, click next.
6
Is the person experiencing memory issues on hospice?* This field is required.
Yes
No
Not sure
7
Is the person experiencing memory issues a long-term nursing home / skilled nursing facility resident? (Note: residents of other types of communities like assisted living, memory care, and senior living facilities should select "NO")* This field is required.Nursing Homes i.e., Skilled Nursing Facilities, are for people with complex health needs requiring 24/7 skilled nursing care. These facilities are different than Assisted Living Communities, Memory Care facilities, and Senior Living Communities
Yes
No
Not sure
8
Does the person seeking care have any supplementary insurance besides Traditional Medicare Parts A&B?* This field is required.HMO and Medicare Advantage plans can sometimes exclude people from being eligible for the GUIDE program
Yes
No
Not sure
9
Resources from the CMS GUIDE program are not yet available through Memory Connect in the selected state - but it's coming soon, and we can connect you to other care options until then.You are a strong candidate, so keeping info in our system will allow us to reach back out if an when it becomes available in the state you selected as the location of care
Ok, give me my options
10
Resources from the CMS GUIDE program are not available if primary coverage comes from a Medicare Advantage, HMO, or PPO plan - Traditional Medicare Parts A&B must be primary coverageThe CMS GUIDE program is new as of 2024 - you may wish to speak with a Memory Connect insurance specialist about resources available through your coverage for your next election. Regardless of insurance, it is important to work with a provider knowledgeable in geriatric care. Memory connect can help set up an appointment with an insurance specialist, or one of these providers.
Ok, give me my options
11
Resources from the CMS GUIDE program are not available if the beneficiary has started receiving hospice benefitsWe'll quickly share other care options that may be of interest to you.
Ok, give me my options
12
Resources from the CMS GUIDE program are not available for long-term nursing home / skilled nursing facility residents (note: it is available for assisted living, memory care, and senior living community residents)If the stay may be short-term or circumstances may change, having your GUIDE info submitted to Medicare allows CMS to automatically start program benefits when they become applicable for the beneficiary; also, nursing homes / skilled nursing facilities are NOT the same as senior living communities, assisted living, or memory care facilities.
Ok, give me my options
13
We have identified your care options - geriatric primary care, palliative care, and psychiatry are available. We can also set you up for a consultation with an insurance specialist. Which would you like to explore?
Geriatric primary care
Geriatric palliative care
Geriatric psychiatry
Insurance specialist consultation
14
Geriatric primary care
TRUE
15
Geriatric palliative care
TRUE
16
Geriatric psychiatry
TRUE
17
Insurance specialist consultation
Out of Network
18
We can check your eligibility - if supplemental coverage is not from a HMO or MA plan, GUIDE still appliesThe CMS GUIDE program is new as of 2024 - criteria is subject to change, but today, Medicare does not allow supplemental coverage from HMO or Medicare Advantage plans to combine with GUIDE program resources. Our support team can run your Medicare Beneficiary ID (MBI) to be sure about you or your loved one's status
Ok, check my eligibility
19
We'll need the applicable Medicare Beneficiary ID (MBI) for verification, which can be found on red, white, and blue Medicare cards. Click next to submit the MBI on the next page.
20
What is the Medicare Beneficiary ID (MBI) for the person experiencing memory issues?* This field is required.
Non-MBI insurance numbers will not enter
21
What is your email?* This field is required.The email that should be used to contact you.
example@example.com
22
What is your phone number?* This field is required.The phone number that should be used to contact you.
Please enter a valid phone number.
23
Get Page URL
24
What is the zip code for the location of care?* This field is required.Zipcode for the individual seeking to receive dementia assistance
25
Referrer
26
utm_source
Please Select
Please Select
Community
GUIDE Event
Other Event
Patient
Provider
Respite Partner
SNF/Rehab
Website
Wellness Coordinator
Meta
Google
Instagram
LinkedIn
Clinical Liaison
Sales Team
Insurance Agent
fbads
googlesearchads
googledisplayads
igads
bingads
activecampaign
displayads
linkedinads
youtubeads
27
utm_medium
Please Select
Please Select
paidsearch
paidsocial
email
display
28
utm_campaign
Please Select
Please Select
p1
p2
p3
29
utm_term
Please Select
Please Select
a
b
c
d
e
f
g
h
i
30
You're almost there! Select "submit" to get the care you deserve.

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