Section I - VETERAN/CLAIMANT'S IDENTIFICATION INFORMATION
SECTION III - GENERAL INFORMATION
(To be completed by a Nursing Home Official)
NOTE: You can either complete the form online or by hand. If completed by hand, print the information requested in ink, neatly, and legibly to expedite processing the form.
REQUEST FOR NURSING HOME INFORMATION IN CONNECTION
WITH CLAIM FOR AID AND ATTENDANCE
VA FORM
FEB 2017
VA DATE STAMP
(Do Not Write In This Space)
21-0779
$
INSTRUCTIONS: If you have any questions about completing this form, call VA toll-free at
1-800-827-1000 (Hearing Impaired TDD federal relay number is 711).
1. VETERAN/CLAIMANT'S NAME (First, Middle Initial, Last)
OMB Approved No: 2900-0652
Respondent Burden: 10 Minutes
Expiration Date: 02/29/2020
3. VA FILE NUMBER
2. VETERAN/CLAIMANT'S SOCIAL SECURITY NUMBER
13. I CERTIFY THAT THE CLAIMANT IS A PATIENT IN THIS FACILITY BECAUSE OF MENTAL OR PHYSICAL DISABILITY AND IS RECEIVING: (Check one)
SECTION II - NURSING HOME INFORMATION
5. VETERAN'S SERVICE NUMBER (If applicable)
I CERTIFY THAT the statements on this form are true and correct to the best of my knowledge and belief.
SUPERSEDES VA FORM 21-0779, MAR 2010,
WHICH WILL NOT BE USED.
4. VETERAN'S DATE OF BIRTH (MM/DD/YYYY)
YearDayMonth
6. NAME OF NURSING HOME
7. ADDRESS OF NURSING HOME (Number and street or rural route, P.O. Box, City, State, ZIP Code and Country)
No. &
Street
Apt./Unit Number
City
ZIP Code/Postal Code
State/Province
Country
8. DATE ADMITTED TO NURSING HOME (MM/DD/YYYY)
YearDayMonth
9. IS THE NURSING HOME FACILITY MEDICAID OR EQUIVALENT APPROVED?
YES NO
10. HAS THE PATIENT APPLIED FOR MEDICAID?
YES
NO
11A. IS THE PATIENT COVERED BY MEDICAID OR
EQUIVALENT PLAN?
YES
NO
(If "YES," complete Item 11B)
YearDayMonth
11B. DATE MEDICAID OR EQUIVALENT PLAN BEGAN
12. MONTHLY AMOUNT PATIENT IS RESPONSIBLE FOR OUT OF POCKET
SKILLED NURSING CARE INTERMEDIATE NURSING CARE
14. NURSING HOME OFFICIAL'S NAME (First and Last) (Please print)
15. NURSING HOME OFFICIAL'S
TITLE (Please print)
16. NURSING HOME OFFICIAL'S OFFICE TELEPHONE
NUMBER (Include Area Code)
SECTION IV - DECLARATION OF INTENT
17. SIGNATURE OF NURSING HOME OFFICIAL (Sign in ink)
18. DATE SIGNED (MM,DD,YYYY)
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 www.reginfo.gov/public/do/PRAMain. If you desire, you can call 1-800-827-1000 to get
information on where to send comments or suggestions about this form.
