Healthcare Eligibility Check

This is demonstration form for testing purposes

Do not use this form in your final application. Ask your partner organization about how to configure this form for your application.

Beneficiary First Name*

Beneficiary Last Name*

Beneficiary Date of Birth*

Medicare Beneficiary Identifier*

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

Does Beneficiary need help managing daily activities, specifically handling finances or personal care? *

Yes

Does 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 Beneficiary currently receiving GUIDE services?*

Select 'No' if patient is not enrolled in GUIDE

Yes

Your Phone Number*

Your Email*

If you're a member of a referring organization, please list that organization here

By clicking "Check Eligibility," you agree to our Privacy Policy and authorize Eli Health, Crosby Health and Demo Partner to use your information to verify eligibility for the GUIDE model.

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