Alzheimer's Disease or dementia services

If you have been diagnosed with Alzheimer’s Disease or dementia and need personal care services and/or consumer directed personal assistance services, you can request an assessment from the New York Independent Assessor Program. This assessment will also help determine if you can request to enroll in a Managed Long Term Care plan. 

Before your assessment, you should ask your health care provider to complete the Alzheimer’s Disease and Dementia Diagnosis Verification Form.

Follow each step to complete and return the form:

• To access and download the Alzheimer Disease and Dementia Diagnosis Verification Form, click here. 
• Ask your provider to fill out the form and provide you a copy.
• Submit the completed form by fax. You or your provider can submit the completed form by fax to: 917-228-8601. If you would like, you can send the form using the New York Independent Assessor Program (NYIAP) Fax Cover Sheet, which you can download and print by clicking here. This cover sheet includes the NYIAP fax number and helps to ensure your information is kept confidential. 

Note: If you have an Alzheimer’s Disease or dementia diagnosis and are not able to fax a completed Alzheimer’s Disease and Dementia Diagnosis Verification Form before your assessment appointments, you can bring a copy of the form to the appointments. 

If you are not able to provide this form at the time of your assessment appointments, the diagnosis cannot be considered in relation to your health assessment results.