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N-648 Patient Information
Only applicants with severe memory loss or severe cognitive impairment meet medical necessity for N-648 certification. If the applicant's memory loss or cognitive impairment is mild or moderate, the applicant will not qualify and we will not accept the case. A family member or caregiver may complete this form for the applicant.
Confirmation
*
I understand that only applicants with severe memory loss or severe cognitive impairment meet medical necessity for N-648 certification, and the information I provide will be true and correct.
Applicant's Family Name (Last Name)
*
Applicant's Given Name (First Name)
*
Applicant's Middle Name (if any)
Alien Registration Number (A-Number) (if any) - 9 digits; add leading zeros if shorter
Applicant Date of Birth (mm/dd/yyyy)
/
Month
/
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Language the applicant speaks
*
Street Number and Name
Apartment, Suite, or Floor Number (if any)
City or Town
State
ZIP Code
Applicant's Telephone Number
Format: (000) 000-0000.
Applicant's Email Address (if any)
In-Person Interpreter's Family Name (Last Name) (if any)
Interpreter's Given Name (First Name)
Interpreter's Middle Name (if applicable)
Interpreter's Daytime Telephone Number
Format: (000) 000-0000.
Interpreter's Mobile Telephone Number (if any)
Format: (000) 000-0000.
Interpreter's Email Address (if any)
example@example.com
Person Completing this Form, if Other Than the Applicant (full name)
Relationship to the applicant
Preparer's Telephone Number
Preparer's Email Address
Submit
Should be Empty: