Application For Furnishing Long-Term Care Services To Beneficiaries Of Veterans Affairs Page 2
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2APPLICATION FOR FURNISHING LONG-TERM CARE
SERVICES TO BENEFICIARIES OF VETERANS AFFAIRS, CONTINUED
(Case-mix/level of care)
(Price)
13. FINAL SCHEDULE OF SERVICES
14. AMOUNT
(Attach additional sheets as necessary.)
16. PROVIDER AGREEMENT NUMBER
15A. THE PROVIDER IS REQUESTED TO SIGN THIS DOCUMENT
AND RETURN THE NUMBER OF COPIES SPECIFIED BELOW TO
THE ISSUING OFFICE.
PROVIDER AGREES TO FURNISH AND
DELIVER ALL ITEMS SET FORTH OR OTHERWISE IDENTIFIED
17. EFFECTIVE DATES OF AGREEMENT
ABOVE AND ON ANY ADDITIONAL SHEET SUBJECT TO THE
(Start date/end date)
TERMS AND CONDITIONS SPECIFIED.
15B. NUMBER OF COPIES REQUIRED BY ISSUING OFFICE
18A. SIGNATURE OF PROVIDER
19A. SIGNATURE OF VA CENTER DIRECTOR OR DESIGNEE
18C. DATE SIGNED 19B. NAME OF VA CENTER DIRECTOR OR
19C. DATE SIGNED
18B. NAME AND TITLE OF SIGNER
(Type or Print)
(Type or Print)
DESIGNEE
20. COMMENTS
VA FORM
10-1170
SUPERSEDES VA FORM 10-1170, MAR 2004, WHICH WILL NOT BE USED.
Page 2 of 2
NOV 2006 (RS)
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