Medicare Now Pays
For Dementia Support
See how families access care navigation, caregiver training, and respite services
without paying out of pocket.
Referring Organization Name
Your Name
Your Email Address
Your Phone Number
Patient Full Name
*
Patient Date of birth
*
Patient Phone Number
*
Patient Medicare Number (MBI)
*
Patient Postal Code
*
Does the patient have a caregiver?
Yes
No
Caregiver Full Name
*
Caregiver Birth Day
*
Caregiver Email Address
*
Relationship to Patient
*
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
