Healthcare Eligibility Check

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)

Address*

Potential GUIDE Beneficiary's address line 1

Potential GUIDE Beneficiary's address line 2

State*

Potential GUIDE Beneficiary's state

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 Long-Term Skilled Nursing Facility, Memory Care, or Assisted Living facility?*

Long-Term Skilled Nursing means the beneficiary lives at the facility full-time, with no planned move-out date. This is different from a Short Stay (sometimes called "rehab" or "post-acute care"), where someone goes to a skilled nursing facility temporarily after a hospital stay, usually for a few weeks to recover and return home.

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

1. Submitter Details

2. Potential GUIDE Beneficiary Information

3. Caregiver or Authorized Representative Information