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ARE YOU ELIGIBLE FOR GUIDE?

Please answer the questions below honestly to determine whether you qualify for the GUIDE program. Once you click submit, a member of the GUIDE care team will reach out to inform you of your eligibility.​

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You can also download a copy of our referral form and email it to GUIDE@agingihs.org.

Is the individual on Medicare Part A and B?
Yes
No
Has the individual been diagnosed with dementia or are they displaying symptoms of memory loss?
Yes
No
Check any that apply to the individual.
Contact's relationship to person needing assistance:
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