Medicare Now Pays

For Dementia Support

See how families access care navigation, caregiver training, and respite services

without paying out of pocket.

Has the patient received a formal diagnosis of Dementia or Alzheimer’s? *

Yes

No

Is the patient enrolled in Original/Traditional Medicare (Part A & B)? *

Yes

No

Is the patient enrolled in a Medicare Advantage Plan or PACE Program? *

Yes

No

Is the patient currently in Hospice or a long-term Nursing Home? *

Yes

No

Patient Full Name *

Patient Date of birth *

Patient Phone Number *

Patient Email Address *

Patient Medicare Number (MBI) *

Patient Postal Code *

Do you have a caregiver?

Yes

No

Caregiver Full Name *

Caregiver Birth Day *

Caregiver Email Address *

Relationship to Patient *

Final Step: How Can We Help? (Select all that apply) *

Respite Care (Break for the caregiver)

Care Navigation (Guidance & Support)

Adult Day Care

24/7 Support Line

Who is the patient's primary doctor or clinic? (Optional)

Doctor/Clinic Phone number (Optional)

On a scale of 1-10, how overwhelmed do you feel as a caregiver right now? (1 = Managing well, 10 = Need urgent help) *

How did you hear about MedBetterHealth? *

Doctor Referral

Social Media

Email / Postcard

Word of Mouth

Other

Please Specify

By clicking "Submit," you grant MedBetterHealth and its Care Coordination team permission to contact you via phone, email, or SMS regarding the results of this assessment and to discuss next steps for dementia support services.

We take your privacy seriously. By submitting this form, you acknowledge that the information provided will be used strictly to determine eligibility for the CMS GUIDE Model program. Your data will be stored securely and will not be shared with unauthorized third parties without your express consent.

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