Vba Form 21-0779 Request For Nursing Home Information In Connection With Claim For Aid And Attendance

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OMB Approved No: 2900-0652

RESPONDENT BURDEN: 10 Minutes

VA DATE STAMP

REQUEST FOR NURSING HOME INFORMATION IN

(Do Not Write In This Space)

CONNECTION WITH CLAIM FOR AID AND ATTENDANCE

INSTRUCTIONS: For free help in completing this form, call VA toll-free at 1-800-827-1000. (Hearing Impaired TDD

line 1-800-829-4833.)

Section I - IDENTIFICATION INFORMATION

1A. NAME OF NURSING HOME

1B. ADDRESS OF NURSING HOME

2. ADDRESS OF VA REGIONAL OFFICE

3. FIRST NAME - MIDDLE INITIAL- LAST NAME OF CLAIMANT

4. SOCIAL SECURITY NUMBER

5. VA FILE NUMBER

SECTION II - NURSING HOME INFORMATION (To be completed by a Nursing Home Official)

(Month, Day, Year)

6. DATE ADMITTED TO NURSING HOME

7. DATE MEDICAID BEGAN

8. AMOUNT PATIENT IS RESPONSIBLE FOR OUT OF POCKET

9. I CERTIFY THAT THE CLAIMANT IS A PATIENT IN THIS FACILITY BECAUSE OF MENTAL OR PHYSICAL DISABILITY AND IS RECEIVING:

(Check one)

SKILLED NURSING CARE

INTERMEDIATE NURSING CARE

(First & Last) (Please print)

10. NURSING HOME OFFICIAL'S NAME

(Please print)

12. NURSING HOME OFFICIAL'S OFFICE

11. NURSING HOME OFFICIAL'S TITLE

(Include Area Code)

TELEPHONE NUMBER

13A. SIGNATURE OF NURSING HOME OFFICIAL

13B. DATE SIGNED

PRIVACY ACT NOTICE: The VA will not disclose information collected on this form to any source other than what has been authorized under the

Privacy Act of 1974 or Title 5, Code of Federal Regulations 1.526 for routine uses (i.e., civil or criminal law enforcement, congressional

communications, epidemiological or research studies, the collection of money owed to the United States, litigation in which the United States is a

party or has an interest, the administration of VA programs and delivery of VA benefits, verification of identity and status, and personnel

administration) as identified in the VA system of records, 58VA21/22/28 Compensation, Pension, Education, and Vocational Rehabilitation and

Employment Records - VA, published in the Federal Register. While you are not required to respond, your cooperation in providing this relevant and

necessary information will help us determine the claimant's maximum benefit entitlement under the law. Information that you furnish may be utilized

in computer matching programs with other Federal or state agencies for the purpose of determining the claimant's eligibility to receive VA benefits, as

well as to collect any amount owed to the United States by virtue of the claimant's participation in any benefit program administered by the

Department of Veterans Affairs.

RESPONDENT BURDEN: We need this information to determine eligibility for benefits and the proper rate of payment (38 U.S.C. 5503, 38 U.S.C.

1115 (1)(E)), 38 U.S.C. 1311(c), 38 U.S.C. 1315(h)). Title 38, United States Code, allows us to ask for this information. We estimate that you will

need an average of 10 minutes to review the instructions, find the information and complete this form. VA cannot conduct or sponsor a collection of

information unless a valid OMB control number is displayed. You are not required to respond to a collection of information if this number is not

displayed. Valid OMB control numbers can be located on the OMB Internet Page at

If you desire, you can call 1-800-827-1000 to get information on where to send comments or suggestions about this form.

VA FORM

21-0779

SUPERSEDES VA FORM 21-0779, MAR 2004,

MAR 2010