10-0460 Request for Prescription Drugs from an Eligible Veteran

OMB Approval No. 2900-XXXX
Estimated Burden: 30 minutes

Request for Prescription Drugs from an Eligible Veteran in a State Home
VA Facility

Name and Address of State Home
From:

To:

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
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is or

is not attached with this request)
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Diagnosis/Diagnoses for which the Applicant was Admitted to the State Nursing Home
Diagnosis Code

Category of Eligibility from page 1

Diagnosis Name

(1, 2, 3 or 4)

Telephone Number:

Name of Prescribing Physician:
I certify that the following medications are prescribed for

Veteran's Name

.

Signature of State Home Representative
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The Paperwork Reduction Act of 1995 requires us to notify you that this information collection
is in accordance with the clearance requirements of section 3507 of this Act. We may not conduct
or sponsor, and the respondent is not required to respond to, a collection unless it displays a valid
OMB Control Number. The public reporting burden for this collection of information is estimated
to average 30 minutes per response, including the time for reviewing instructions, gather the
necessary facts and fill out the form. This information is collected under the authority of Title 38
CFR Parts 51 and 58. It is being collected under the medical benefits in the State Homes Program
and will be used for that purpose.
Privacy Act Information: It is being collected to enable us to determine your eligibility for
medical benefits and will be used for that purpose. The income and eligibility you supply may be
verified through a computer matching program at any time and information may be disclosed
outside the VA as permitted by law; possible disclosures include those described in the "routine
uses" identified in the VA system of records 24VA136, Patient Medical Record-VA, published in
the Federal Register in accordance with the Privacy Act of 1974. Disclosure is voluntary;
however, the information is required in order for us to determine your eligibility for the medical
benefit for which you have applied. Failure to furnish the information will have no adverse affect
on any other benefits to which you may be entitled. Disclosure of Social Security number(s) of
those for whom benefits are claimed is requested under the authority of Title 38, U.S.C., and is
mandatory. Social Security numbers will be used in the administration of veterans benefits, in the
identification of veterans or persons claiming or receiving VA benefits and their records and may
be used for other purposes where authorized by Title 38, U.S.C., and the Privacy Act of 1974 (5
U.S.C. 552a) or where required by other statute

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