SECTION I - VETERAN'S IDENTIFICATION INFORMATION
SECTION IV - GENERAL INFORMATION (To be completed by a Nursing Home Official)
NOTE: You may complete the form online or by hand. If completing by hand, print neatly and legibly in ink, and completely fill in each applicable circle to help expedite processing
of the form.
REQUEST FOR NURSING HOME INFORMATION IN CONNECTION
WITH CLAIM FOR AID AND ATTENDANCE
VA FORM
AUG 2020
VA DATE STAMP
(Do Not Write In This Space)
21-0779
$
INSTRUCTIONS: Before completing this form, read the Privacy Act and Respondent Burden. We use
this form to determine eligibility in connection with a claim for aid and attendance. For more
information, contact us at https://iris.custhelp.va.gov, or call us toll-free at 1-800-827-1000. If you
use a Telecommunications Device for the Deaf (TDD), the Federal relay number is 711. VA forms are
available at www.va.gov/vaforms. After completing the form, mail to: Department of Veterans
Affairs, Evidence Intake Center, P.O. Box 4444, Janesville, WI, 53547- 4444.
1. VETERAN'S NAME (First, Middle Initial, Last)
OMB Approved No: 2900-0652
Respondent Burden: 10 Minutes
Expiration Date: 08/31/2023
3. VA FILE NUMBER
2. SOCIAL SECURITY NUMBER
16. I CERTIFY THAT THE CLAIMANT IS A PATIENT IN THIS FACILITY BECAUSE OF MENTAL OR PHYSICAL DISABILITY AND IS RECEIVING: (Check one)
SECTION III - NURSING HOME INFORMATION
SUPERSEDES VA FORM 21-0779, FEB 2017.
4. DATE OF BIRTH (MM/DD/YYYY)
9. NAME OF NURSING HOME
10. 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
11. DATE ADMITTED TO NURSING HOME (MM/DD/YYYY)
12. IS THE NURSING HOME A MEDICAID APPROVED FACILITY?
13. HAS THE PATIENT APPLIED FOR MEDICAID?
14A. IS THE PATIENT COVERED BY MEDICAID?
(If "YES," complete Item 14B)
14B. DATE MEDICAID PLAN BEGAN (MM/DD/YYYY)
15. MONTHLY AMOUNT PATIENT IS RESPONSIBLE FOR OUT OF POCKET
17. NURSING HOME OFFICIAL'S NAME (First and Last)
18. NURSING HOME OFFICIAL'S TITLE
19. NURSING HOME OFFICIAL'S OFFICE TELEPHONE
NUMBER (Include Area Code)
YES NO
YES NO
SKILLED NURSING CARE INTERMEDIATE NURSING CARE
YES NO
SECTION II - CLAIMANT'S IDENTIFICATION INFORMATION (Complete this section ONLY IF the claimant is NOT the veteran)
7. VA FILE NUMBER (If applicable)
6. SOCIAL SECURITY NUMBER
8. DATE OF BIRTH (MM/DD/YYYY)
5. CLAIMANT'S NAME (First, Middle Initial, Last)
NOTE: Your state's Medicaid program may use a different name.
SECTION V - CERTIFICATION AND SIGNATURE
I CERTIFY THAT the statements on this form are true and correct to the best of my knowledge and belief.
20. SIGNATURE OF NURSING HOME OFFICIAL (REQUIRED)
21. DATE SIGNED (MM/DD/YYYY)
PENALTY: The law provides severe penalties (including fine and/or imprisonment) for willfully submitting any statement or evidence of a material fact you know to be false, or for
fraudulent receipt of any document you are not entitled to.
Enter International Phone
Number (If applicable)
Page 1
click to sign
signature
click to edit
![]()
