Va Form 10-0460 - Request For Prescription Drugs From An Eligible Veteran In A State Home

Download a blank fillable Va Form 10-0460 - Request For Prescription Drugs From An Eligible Veteran In A State Home in PDF format just by clicking the "DOWNLOAD PDF" button.

Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.

Complete Va Form 10-0460 - Request For Prescription Drugs From An Eligible Veteran In A State Home with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.

Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.

ADVERTISEMENT

OMB Approval No. 2900-0160
Estimated Burden: 30 minutes
Request for Prescription Drugs from an Eligible Veteran in a State Home
VA Facility
Name and Address of State Home
To:
From:
I am a veteran who was admitted to the
State Nursing Home.
I request that I be furnished with prescription drugs by the United States Department of Veterans Affairs as
provided for in Title 38 of the Code of Federal Regulations, Section(s) 17.96 and/or 51.42.
I am eligible for this benefit by reason of being (check any of the following):
(1) a veteran in receipt of increased VA compensation, or increased VA pension because I am permanently housebound or in need
of regular aid and attendance.
(2) a veteran in need of regular aid and attendance who was formerly in receipt of increased pension but whose pension has been
discontinued solely by reason of excess income, and whose annual income does not exceed the maximum annual income limitation
by more than $1,000.
(3) a veteran who
(i) Has a singular or combined rating of 50 percent or 60 percent based on one or more service-connected disabilities or
unemployability and is in need of such drugs and medicines; and
(ii) Is in need of nursing home care for reasons that do not include care for a VA adjudicated service-connected disability.
(4) a veteran who
(i) Has a singular or combined rating of less than 50 percent, based on one or more service-connected disabilities, and is in need of
such drugs and medicines for a service-connected disability, and
(ii) Is in need of nursing home care for reasons that do not include care for a VA adjudicated service-connected disability.
Signature of Veteran Applying for Benefit
Date of Application
Applicant Information
Veteran's Name (last, first, and middle initial):
Veteran's Social Security Number:
Date of Admission to the State Nursing Home:
Date that A&A or Housebound was awarded by VA:
(a copy of this award
is or
is not attached with this request)
10-0460
Page 1 of 3
VA FORM
FEB 2008

ADVERTISEMENT

00 votes

Related Articles

Related forms

Related Categories

Parent category: Legal
Go
Page of 3