Application
	Authorization Letter
	Patient Insurance Information Letter

The Application Instructions, Statistical Form and Instructions, and the College Codes documents are available as Portable Document Format (pdf) files which will require that you have Acrobat Reader installed on your computer. Acrobat Reader is compatible with all computer platforms and can be downloaded at no cost from the Adobe website.

If you would like us to mail you a paper application, please call the Center at (212) 263-8088.

As part of the Center’s diagnostic evaluation the following procedures may be necessary:

It is important for you to understand that these procedures will be billed to your insurance carrier. We accept Medicare and other primary and secondary carriers. Only a small fraction of our diagnostic costs are supported by external funding. We therefore require that our applicants provide insurance information (both Medicare and private insurance) in order for us to bill third parties for the basic diagnostic evaluations performed on participants at our Center. There is no cost for any special procedures done for research purposes.

Please note that in addition to requesting reimbursement from your insurance carriers, we are also required to bill participants directly for any co-payments. Participants without any insurance coverage must also be billed directly.

Please sign the authorization form and return it along with the completed Patient Insurance Information Form. Also, if applicable, please bring a signed insurance form from your medical insurance carrier when you come in for your first appointment. If you are enrolled in a Health Maintenance Organization (HMO) or Managed Care Plan, it is essential that you obtain their prior approval for an evaluation at our Center. Otherwise, they will not approve any reimbursement for our diagnostic procedures. Please send us their required authorization or referral form, or bring it with you on the day of your first appointment.

If you have any questions, please feel free to discuss them with the Clinic Coordinator (212 263-8088) or any other member of our staff at the Aging and Dementia Research Center. We are always available to help you. The ultimate objective of our clinical services and scientific research efforts is the enhancement of the health and welfare of our participants and their families.

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