Healthcare Eligibility Check

1. Submitter Details

Submitter Full Name*

Your Phone Number*

Your Email*

Submitter Role*

2. Potential GUIDE Beneficiary Information

Potential GUIDE Beneficiary's Full Name*

Date of Birth*

Potential GUIDE Beneficiary's date of birth

Medicare Beneficiary Identifier*

11 characters (letters and numbers only, no S, L, O, I, B, or Z)

Zip Code*

Potential GUIDE Beneficiary's zip code

Relationship to You*

Potential GUIDE Beneficiary's relationship

Does potential GUIDE beneficiary need help managing daily activities, specifically handling finances or personal care? *

Yes

Does potential GUIDE beneficiary reside in a Skilled Nursing Facility?*

SNFs offer round-the-clock certified nursing support, usually for individuals needing continuous therapeutic or medical treatment.

Yes

Is potential GUIDE beneficiary currently receiving GUIDE services?*

Select 'No' if patient is not enrolled in GUIDE

Yes

This question helps determine potential eligibility for CMS’s GUIDE Model. It does not guarantee enrollment.

3. Caregiver or Authorized Representative Information

Full Name*

If this is self, please retype your name below

I confirm that I am:*What does this mean?

The Medicare Beneficiary completing this form on my own behalf

An Authorized Representative of the Beneficiary (POA, or legal guardian)

Someone who has received verbal consent to submit this information on the Beneficiary's behalf

By submitting, I acknowledge this form collects health information for clinical coordination under the CMS GUIDE Model. I consent to EmpowerMe Medical Group, P.C., Crosby Health, and Continuum reviewing this information for eligibility purposes.*

This form will not be accessed by EmpowerMe HR or used for employment-related decisions. View our full Privacy Notice here.*

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