GUIDE Referral Form

GUIDE Referral Form
The GUIDE Program is an innovative new Medicare program for individuals with dementia and their caregivers. A spouse, child, sibling, other relative, friend, or neighbor can receive assistance for themselves and their loved one who is experiencing memory loss. The GUIDE Model is focused on improving the quality of life for people living with dementia and their caregivers by reducing strain on caregivers and preventing or delaying institutionalization.

If you have any questions about the GUIDE program or a potential referral, contact the GUIDE team at guide@lsr14.org or 812-948-8330 M-F 8:00 a.m. – 4:30 p.m.

About GUIDE:
- To be referred for GUIDE enrollment, individuals require a potential diagnosis of dementia or exhibiting cognitive impairment and have Medicare Parts A & B (not an Advantage Plan).
- Not currently receiving PACE or Hospice care under Medicare
- There are no age limitations
- Individuals with or without a caregiver are eligible for referral to GUIDE
Referral Information
Date

MonthDayYear
Date
Referral Source (name)

First NameLast Name
Agency:
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Name of Referral

First NameLast Name
MaleFemaleOther
County of Residence:
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Date of Birth:
Medicare Number:
YesNo
Name of Caregiver (if applicable):

First NameLast Name
YesNo
Preferred Contact times and other pertinent information:
Should be Empty:

GUIDE Referral Form

Referral Information