LONG-TERM CARE – DAILY VISIT NOTES AND CARE LOG
NEW YORK LIFE LONG-TERM CARE INSURANCE
PO Box 64670, St. Paul, MN 55164-0670
This form is to be used after New York Life Insurance Company has determined eligibility under the Home
and Community-Based Care Benefit and after the claimant has begun to receive home care services from an
eligible provider.
1. If daily visit notes or a daily log is not already completed by your care provider, please have your
provider complete this Daily Visit Notes and Care Log for each day of services and submit it on a weekly
basis with the weekly care invoice for ongoing claims.
2. The care provider must record the home health care services provided for each day and complete the
entire form.
3. Indicate the date of service under each day of the week.
4. Indicate under Activities of Daily Living and Instrumental Activities of Daily Living whether the care
provided is hands-on assist (HOA), standby assist within arms length (SBA), or not provided (N/P).
5. For Cognitive Impairment Claims Only: Indicate if supervision is provided due to a severe cognitive
impairment by checking the box on those days supervision is provided. Also indicate in the ADLs and
IADLs section if cueing (CUE) is required for the claimant to complete the ADLs or IADLs.
6. The claimant (or legal representative if required) and caregiver must sign and date this form.
7. Return this Daily Visit Notes and Care Log and the weekly care invoice(s) to the address above or send it
via fax to 908-840-3046 or e-fax to claimsfax@newyorklifeltc.com.
