10-10SH State Homes Program Application for Veterans Care Medica

OMB Approval No. 2900-0160
Estimated Burden: Avg. 20 min.
EXP: Jan 31, 2016
VA FORM 10-10SH
STATE HOME PROGRAM APPLICATION FOR VETERAN CARE MEDICAL CERTIFICATION
PART I - ADMINISTRATIVE
1. STATE HOME FACILITY

2. DATE ADMITTED

3. STATE HOME FACILITY ADDRESS (street, city, state and zip code)
4. RESIDENT'S NAME (Last, First, Middle) (This is a mandatory Field)
6. GENDER

5. SOCIAL SECURITY NUMBER (Mandatory Field)

7. AGE

M

8. DATE OF BIRTH (MM/DD/YYYY)

F

9. HAS THE VETERAN PROVIDED FINANCIAL DISCLOSURE FOR PURPOSES OF DETERMINING ELIGIBILITY FOR DOMICILIARY PER DIEM PAYMENTS?
YES
NO
N/A
10-10EZ or 10-10EZR IS REQUIRED TO BE SUBMITTED EITHER IN PAPER FORM OR ELECTRONICALLY WITH THE 10-10SH
PART II - HISTORY AND PHYSICAL (Use separate sheet if necessary)
10. HISTORY

11. HEIGHT

12. WEIGHT

13. TEMP

14. PULSE

15. BP

16. HEAD/EYES/EARS/NOSE AND THROAT

17. NECK

18. CARDIOPULMONARY

19. ABDOMEN

20. GENITOURINARY

21. RECTAL

22. EXTREMITIES

23. NEUROLOGICAL

24. ALLERGY/DRUG SENSITIVITY

CHEST
X-RAY

DATE (MM/DD/YYYY)

RESULT

DATE (MM/DD/YYYY)

CBC

RESULT

25. X-RAY/
SEROLOGY
LAB
URINALYSIS

DATE (MM/DD/YYYY)

ALBUMEN

SUGAR

ACETONE

CHECK ALL BOXES THAT APPLY OR CHECK N/A
26. IS DEMENTIA THE PRIMARY
DIAGNOSIS
YES
NO

27. IS THERE A DIAGNOSIS OF
MENTAL ILLNESS
N/A
YES
NO
N/A

28. HAS THE RESIDENT RECEIVED
MENTAL SERVICES WITHIN THE PAST 2
YEARS
YES
NO
N/A

29. IS CLIENT A DANGER TO SELF
OR OTHERS
YES
NO
N/A

30. IS THERE ANY PRESSING EVIDENCE OR MENTAL ILLNESS SUCH AS:
SCHIZOPHRENIA
PARANOIA
OTHER PSYCHOTIC OR MENTAL DISORDERS LEADING TO CHRONIC DISABILITY
MOOD SWINGS
31. OXYGEN
MASK

SOMATOFORM DISORDER
PRN

NASAL CANULAR

N/A
CONTINUIOUS

PANIC OR SEVERE ANXIETY DISORDER

32. FEEDING
TUBE FEEDING
OSTOMY

33. WOUND
DECUBITUS ULCERS

N/A
TRACHOSTOMY

DRAINING WOUND

35. REFERRING PHYSICIAN

36. PRIMARY DIAGNOSIS

37. SECONDARY DIAGNOSIS

38. TERTIARY DIAGNOSIS

39. ARE THE ADMITTING DIAGNOSIS RELATED TO A SERVICE CONNECTED CONDITION?
40. TYPE OF CARE RECOMMENDED:

SKILLED NURSING HOME CARE

YES

N/A

PERSONALITY DISORDER
34. FOLEY CATHETER
TEMPORARY
N/A

N/A
WOUND CULTURED

PERMANENT

NO

DOMICILIARY CARE

ADULT DAY HEALTH CARE

41. MEDICATION AND TREATMENT ORDERS ON ADMISSION, CONTINUE ON SEPARATE SHEET IF NECESSARY

42. PRINTED OR TYPED NAME OF PRIMARY PHYSICIAN ASSIGNED

VA FORM
JUN 2015

10-10SH

43. SIGNATURE OF PRIMARY PHYSICIAN ASSIGNED

PREVIOUS EDITIONS OF THIS FORM ARE NOT TO BE USED

PAGE 1 of 5

OMB Approval No. 2900-0160
Estimated Burden: Avg. 20 min.
EXP: Jan 31, 2016
VA FORM 10-10SH
STATE HOME PROGRAM APPLICATION FOR VETERAN CARE MEDICAL CERTIFICATION
PART III - EVALUATION (Select an appropriate number in each category)
44. RESIDENT'S NAME (Last, First, Middle ) (This is a mandatory field)

45. SOCIAL SECURITY NUMBER (Mandatory Field)

1. Transmits messages/receives information
2. Limited ability
3. Nearly or totally unable

COMMUNICATION

1. Good
2. Hearing slightly impaired
3. Nearly or totally unable
4. Virtually/completely deaf

HEARING

1. No assistance
2. Equipment only
3. Supervision only
4. Requires human transfer w/wo equipment
5. Bedfast

TRANSFER

1. Tolerates distances (250 feet sustained activity)

2. Needs intermitten rest

ENDURANCE

3. Rarely tolerates short activities
4. No tolerance
1. No assistance
2. Assistance to and from transfer

TOILETING

1. Speak clearly with others of same language
2. Limited ability
3. Unable to speak clearly or not at all

SIGHT

1. Good
2. Vision adequate - Unable to read/see details
3. Vision limited - Gross object differentiation
4. Blind

AMBULATION

1. Independence w/wo assistance device
2. Walks with supervision
3. Walks with continuous human support
4. Bed to chair (total help)
5. Bedfast

MENTAL AND
BEHAVIOR
STATUS

1. Alert
2. Confused
3. Disoriented
4. Comatose

5. Agreeable
6. Disruptive
7. Apathetic
8. Well motivated

1. No assistance

A. Tub

2. Supervision Only

B. Shower

3. Assistance

C. Sponge bath

A. Bathroom
B. Bedside
commode

3. Total assistance including
personal hygiene, help with
clothes

SPEECH

BATHING

C. Bedpan

DRESSING

1. Dresses self
2. Minor assistance
3. Needs help to complete dressing
4. Has to be dressed

BLADDER
CONTROL

1. Continent
2. Rarely incontinent
3. Occasional - once/week or less
4. Frequent - up to once a day
5. Total incontinence
6. Catheter, indwelling

SKIN
CONDITION

1. Intact
2. Dry/Fragile
3. Irritations (Rash)
4. Open wound
5. Decubitus

4. Is bathed

FEEDING

1. No assistance
2. Minor assistance, needs tray set up only
3. Help feeding/encouraging
4. Is fed

BOWEL
CONTROL

1. Continent
2. Rarely incontinent
3. Occasional - once/week or less
4. Frequent - up to once a day
5. Total incontinence
6. Ostomy
1. Independence

Number:

2. Assistance in difficult maneuvering

WHEEL CHAIR
USE

Stage:

3. Wheels a few feet
4. Unable to use

PHYSICAL THERAPY (To be completed by Physical Therapist or Referring Physician) 48. Check if
49. SENSATION IMPAIRED
YES

NO

YES

53. TREATMENT GOALS:
STRETCHING

50. RESTRICT ACTIVITY
NO

ACTIVE

ACTIVE ASSISTIVE

NEW REFERRAL

51. PRECAUTIONS
CARDIAC

OTHER

(Type other, specify)

SPEECH

CONTINUATION OR THERAPY
52. FREQUENCY OF TREATMENT

COORDINATING ACTIVITIES

FULL WEIGHT BEARING

WHEELCHAIR INDEPENDENT

NON-WEIGHT BEARING

PROGRESS BED TO WHEELCHAIR

COMPLETE AMBULATION

PROGRESSIVE RESISTIVE
PASSIVE ROM
PARTIAL WEIGHT BEARING
RECOVERY TO FULL FUNCTION
54. ADDITIONAL THERAPIES
55. SIGNATURE AND TITLE OF THERAPIST OR PHYSICIAN
O.T.

N/A

47. DATE:

46. SIGNATURE OF REGISTERED NURSE OR REFERRING PHYSICIAN

56. DATE:

DIETARY
PART IV SOCIAL WORK ASSESSMENT (To be completed by Social Worker)

57. PRIOR LIVING ARRANGEMENTS

58. LONG RANGE PLAN

59. ADJUSTMENT TO ILLNESS OR DISABILITY

60. PRINT NAME OF SOCIAL WORKER

61. SIGNATURE OF SOCIAL WORKER

62. DATE:

63. REMARKS:

VA FORM
JUN 2015

10-10SH

PREVIOUS EDITIONS OF THIS FORM ARE NOT TO BE USED

PAGE 2 of 5

OMB Approval No. 2900-0160
Estimated Burden: Avg. 20 min.
EXP: Jan 31, 2016
VA FORM 10-10SH
STATE HOME PROGRAM APPLICATION FOR VETERAN CARE MEDICAL CERTIFICATION
PART V VA AUTHORIZATION FOR PAYMENT
ADMINISTRATIVE REVIEW

CLINICAL REVIEW

64. 10-10EZ or 10-10EZR RECEIVED WITH 10-10SH
YES
NO
65. DATE ADMITTED TO SVH

77. SERVICE CONNECTED CONDITION BEING ADMITTED FOR:

ELECTRONIC VERSION
66. DATE RECEIVED BY VA
NURSING HOME CARE
78. IS VETERAN BEING ADMITTED DUE TO SC CONDITION:

NURSING HOME CARE
67. SERVICE CONNECTED CONDITION RATING GREATER OR
EQUAL TO 70%:
YES
NO
68. DOES VETERAN HAVE A RATING OF TOTAL DISABILITY BASED ON
INDIVIDUAL UNEMPLOYABILITY:
YES
NO
69. ELIGIBLE FOR PER DIEM PAYMENT NURSING HOME CARE:
YES

YES
YES

BASIC

DOMICILIARY CARE

YES

YES

ADULT DAY HEALTH CARE
71. ELIGIBLE FOR PER DIEM PAYMENT FOR ADULT DAY HEALTH CARE:

YES
DOMICILIARY CARE

NO

ADULT DAY HEALTH CARE

72. DOES INCOME EXCEED THRESHOLD FOR AID & ATTENDANCE:

83. IF NOT ENROLLED IN ADHC, WILL VETERAN REQUIRE NURSING HOME
CARE: (38 U.S.C. 1720,(F)(1)(A))

NO

YES

73. ELIGIBLE FOR PER DIEM PAYMENT DOMICILIARY CARE:
YES

NO

82. VETERAN APPROVED FOR DOMICILIARY LEVEL OF CARE:

NO

YES

NO

81. DOES HEALTH AND /OR FUNCTIONAL DEFICITS RENDER VETERAN
UNABLE OF PURSUING SUBSTANTIALLY GAINFUL EMPLOYMENT:

PREVAILING

YES

NO

80. DOES VETERAN HAVE MEANS TO PROVIDE FOR SELF OR PROVIDED
FOR IN THE COMMUNITY:

NO

70. APPROVED PER DIEM RATE:

NO

79. VETERAN APPROVED FOR NURSING HOME LEVEL OF CARE:

NO

84. VETERAN APPROVED FOR ADULT DAY HEALTH CARE:

NO, ADDITIONAL ELIGIBILITY REQUIREMENTS

YES

NO

85. REMARKS:

74. REMARKS:

75. SIGNATURE OF VA ADMINISTRATIVE REVIEWER

76. DATE:

86. SIGNATURE OF VA PHYSICIAN/ANRP/PA

87. DATE:

PAPERWORK REDUCTION ACT OF 1995 AND PRIVACY ACT STATEMENT
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 the Paperwork Reduction Act of 1995. We may not conduct or sponsor, and you are not required to respond to, a collection of
information unless it displays a valid OMB number. We anticipate that the time expended by all individuals who must complete this form will
average 20 minutes. This includes the time it will take to read instructions, gather the necessary facts and fill out the form. Although completion of
this form is voluntary, VA will be unable to provide reimbursement for services rendered without a completed form. Failure to complete the form will
have no effect on any other benefits to which you maybe entitled. This information is collected under the authority Of Title 38 CFR Parts 51 and 52.
The information requested on this form is solicited under the authority of Title 38, U.S.C., Sections 1741, 1742 and 1743. It is being collected to
enable us to determine your eligibility for medical benefits in the State Home Program 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 voluntary. 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.
VA FORM
JUN 2015

10-10SH

PREVIOUS EDITIONS OF THIS FORM ARE NOT TO BE USED

PAGE 3 of 5

OMB Approval No. 2900-0160
Estimated Burden: Avg. 20 min.
EXP: Jan 31, 2016
VA FORM 10-10SH
INSTRUCTIONS FOR
STATE HOME PROGRAM APPLICATION FOR VETERAN CARE MEDICAL CERTIFICATION
As a condition for VA approved State Veterans Home (SVH) receive payment of per diem, the State home must submit to the VA medical center of
jurisdiction for each veteran a completed VA Form 10-10SH, State Home Program Application for Care--Medical Certification and a 10-10EZ,
Application for Health benefits or 10-10EZR, Health Benefits Renewal Form. This form must be submitted at the time of admission and with any request
for a change in the level of care (domiciliary, nursing home care or adult day health care).
PART I-ADMINISTRATIVE
This section must be completed in full by State Veterans Home designated staff.
1. STATE HOME FACILITY-Enter the name of the facility
2. DATE ADMITTED-Select the date admitted using the calendar or enter
the date as MM/DD/YYY
3. STATE HOME FACILITY ADDRESS- Enter complete address
4. RESIDENT'S NAME-Enter the full name of the person in which this
application applies
5. SOCIAL SECURITY NUMBER-Enter the full social security number of
the applicant

6.
7.
8.
9.

GENDER-Check the appropriate box
AGE-Age of applicant
DATE OF BIRTH-Enter the date of birth in the format MM/DD/YYYY
HAS THE VETERAN PROVIDED FINANCIAL DISCLOSURE FOR
PURPOSES OF DETERMINING ELIGIBILITY FOR DOMILICIARY PER
DIEM PAYMENTS-check yes or no

PART II-HISTORY AND PHYSICAL
This section must be completed in full by State Veterans Home designated staff. The completed VA Form 10-10SH must contain sufficient medical
information to justify the level of care that is to be provided to the Veteran. Failure to submit or complete this form correctly may result in denial or delay
of VA per diem payment.
10:
11.
12.
13.
14.
15.
16.
17.
18.
19.
20.
21.
22.
23.
24.
25.
26.
27.

HISTORY-Enter the patient background and history
HEIGHT-Enter the applicant's height
WEIGHT-Enter the applicant's weight
TEMP-Enter the applicant's temperature
PULSE-Enter the applicant's pulse rate
BP-Enter the applicant's blood pressure
HEAD/EYES/EARS/NOSE AND THROAT-Enter any problems with
the head, eyes, ears, nose and throat
NECK-Enter any problems with the neck
CARDIOPULMONARY-Enter any problems with the heart
ABDOMEN-Enter any problems with the abdomen
GENITOURINARY-Enter any problems with the genitourinary
RECTAL-Enter any problems with the rectum
EXTREMITIES-Enter any problems with the extremities
NEUROLOGICAL-Enter any problems neurologically
ALLERGY/DRUG SENSITIVITY-Enter any allergies or sensitivities
X-RAY/LAB-Date of chest x-ray, results; CBC date, result; serology;
urinalysis date, albumen, sugar, acetone
IS DEMENTIA THE PRIMARY DIAGNOSIS- Check yes, no or N/A
(not applicable)
IS THERE A DIAGNOSIS OF MENTAL ILLNESS-Check yes, no or
N/A (not applicable)

28. HAS THE RESIDENT RECEIVED MENTAL SERVICES WHITHIN
THE PAST 2 YEARS-Check yes, no or N/A (not applicable)
29. IS CLIENT A DANGER TO SELF OR OTHERS-Check yes, no or N/A
(not applicable)
30. IS THERE ANY PRESSING EVIDENCE OR MENTAL ILLNESS
SUCH AS- Check all that apply or check N/A
31. OXYGEN-Check all that apply or check N/A
32. FEEDING-Check all that apply or check N/A
33. WOUND-Check all that apply or check N/A
34. FOLEY CATHETER-Check all that apply or check N/A
35. REFERRING PHYSICIAN- Enter the name of the referring physician
36. PRIMARY DIAGNOSIS-Enter the primary diagnosis
37. SECONDARY DIAGNOSIS-Enter the secondary diagnosis
38. TERTIARY DIAGNOSIS-Enter the tertiary diagnosis
39. ARE THE ADMITTING DIAGNOSIS RELATED TO A SERVICE
CONNECTED CONDITION- Enter yes or no
40. TYPE OF CARE RECOMMENDED-Choose the appropriate care
41. MEDICATION AND TREATMENT ORDERS ON ADMISSION,
CONTINUE ON SEPARATE SHEET IF NECESSARY- Enter all
medications and treatment orders on the applicant.
42. PRINTED OR TYPED NAME OF PRIMARY PHYSICIAN
ASSIGNED-Enter the name of the physician
43. SIGNATURE OF PRIMARY PHYSICIAN-Enter signature

PART III - EVALUATION
44. RESIDENT'S NAME-Enter the full name of the person in which this
50. RESTRICT ACTIVITY- Check yes or no
application applies
51. PRECAUTIONS-Check if there is a cardiac or other (for other type
45. SOCIAL SECURITY NUMBER-Enter the full social security number of
over the text in the box)
the applicant
52. FREQUENCY OF TREATMENT-Enter often the applicant receives
physical therapy
46. SIGNATURE OF REGISTERED NURSE OR REFERRING
53. TREATMENT GOALS-Check all that apply
PHYSICIAN-Enter signature
54. ADDITIONAL THERAPIES-Check all that apply
47. DATE- Enter date signed by registered nurse or referring physician
55. SIGNATURE AND TITLE OF THERAPIST OR PHYSICIAN- Enter the
signature
PHYSICAL THERAPY
56. DATE-Enter the date the Therapist or Physician signed (format
MM/DD/YYYY)
48. Check the box if new of continued therapy
49. SENSATION IMPAIRED-Check yes or no
PART IV SOCIAL WORK ASSESSMENT (To be completed by Social Worker)
57. PRIOR LIVING ARRANGEMENTS
58. LONG RANGE PLAN
59. ADJUSTMENT TO ILLNESS OR DISABILITY
VA FORM
JUN 2015

10-10SH

60.
61.
62.
63.

PRINT NAME OF SOCIAL WORKER
SIGNTURE OF SOCIAL WORKER
DATE
REMARKS

PREVIOUS EDITIONS OF THIS FORM ARE NOT TO BE USED

PAGE 4 of 5

OMB Approval No. 2900-0160
Estimated Burden: Avg. 20 min.
EXP: Jan 31, 2016
VA FORM 10-10SH
INSTRUCTIONS FOR
STATE HOME PROGRAM APPLICATION FOR VETERAN CARE MEDICAL CERTIFICATION
PART V - VA AUTHORIZATION FOR PAYMENT
Completed in full by VA Medical Center of Jurisdiction designated staff
ADMINISTRATIVE REVIEW SECTION

NURSING HOME CARE

64. 10-10EZ OR 10-10EZR RECIEVED WITH 10-10SH-Check the
78. IS VETERAN BEING ADMITTED DUE TO SERVICE CONNECTED
appropriate if the forms were received with the 10-10SH or if the forms
CONDITION. Check YES or NO.
were completed electronically.
79. VETERAN APPROVED FOR NURSING HOME LEVEL OF CARE 65. DATE ADMITTED TO SVH-Enter the date the Veteran was physically
Check YES or NO.
admitted to the State Veteran's Home
66. DATE RECEIVED BY VA-Enter the date the complete admission
DOMICILIARY CARE
application was received by the VA.
80. DOES VETERAN HAVE MEANS TO PROVIDE FOR SELF OR
NURSING HOME CARE
PROVIDED FOR IN THE COMMUNITY- Check YES or NO.
81. DOES HEALTH AND/OR FUNCTIONAL DEFICITS RENDER
67. SERVICE CONNECTED CONDITION RATING GREATER OR EQUAL
VETERAN UNABLE OF PURSUING SUBSTANTIALLY GAINFUL
TO 70%-Check YES or NO if the Veteran is 70% SC.
EMPLOYMENT- Check YES or NO. If Veteran is unable to pursue
68. DOES VETERAN HAVE A RATING OF TOTAL DISABILITY BASED
substantially gainful employment and the clinical provider (reviewer)
ON INDIVIDUAL UNEMPLOYABILITY?-Check YES or NO.
determines the Veteran has health and functioning deficits that require
69. ELIGIBLE FOR PER DIEM PAYMENT NURSING HOME CARE-Check
domiciliary care in the SVH and the Veteran is capable of performing
YES or NO
the following daily living activities:
70. APPROVED PER DIEM RATE-Check either, Basic or the Prevailing
(1) Perform without assistance daily adulations, such as brushing
rate.
teeth, bathing, combing hair, and body eliminations.
(2) Dress self, with minimum of assistance.
ADULT DAY HEALTH CARE
(3) Proceed to and return from the dining hall without aid.
(4) Feed self.
71. ELIGIBLE FOR PER DIEM PAYMENT FOR ADULT DAY HEALTH
(5) Secure medical attention on an ambulatory basis or by use of
CARE-Check YES or NO.
personally propelled wheelchair.
(6) Have voluntary control over body eliminations or control by use of
DOMICILIARY CARE
an appropriate prosthesis.
(7) Share in some measure, however slight, in the maintenance and
72. DOES INCOME EXCEED THRESHOLD FOR AID & ATTENDANCEoperation of the facility.
Indicate if the Veterans annual income exceeds the maximum amount
(8) Make rational and competent decisions as to his or her desire to
of someone in receipt of Aid & Attendance for the following categories;
remain or leave the facility.
Single Veteran, Veteran with Spouse/Dependent, Two Veterans
If all the above conditions are met, check "Yes" in the appropriate box.
Married to Each Other, Surviving Spouse, or Surviving Spouse with
If these conditions are not met, check "No". If any of the above
One Dependent.
questions are answered "No", per diem is not approved.
73. ELIGIBLE FOR PER DIEM PAYMENT DOMICILIARY CARE- Enter
82. VETERAN APPROVED FOR DOMICILIARY LEVEL OF CARE-Check
YES if eligible and NO is there are additional eligibility requirements
yes or no.
74. REMARKS- Enter any remarks regarding this section.
75. SIGNATURE OF VA ADMINISTRATIVE REVIEWER-Enter signature ADULT DAY HEALTH CARE
76. DATE-Date VA Administrator signed
83. IF NOT ENROLLED IN ADHC, WILL VETERAN REQUIRE NURSING
CLINICAL REVIEW SECTON
HOME CARE: (38 U.S.C. 1720, (F)(1)(A))-Check YES or NO.
84. VETERAN APPROVED FOR ADULT DAY HEALTH CARE:
77. SERVICE CONNECTED CONDITION BEING ADMITTED FOR-If
85. REMARKS-Enter any remarks regarding this section.
necessary, review VA databases such as VISTA, HINQ, VIS or CPRS 86. SIGNATURE OF VA PHYSICIAN/ADVANCED REGISTERED NURSE
for Veteran's service-connection condition/rating. Enter the service
PRACTITIONER (ARNP) OR PHYSICIAN ASSISTANT (PA)- Enter
connected condition the Veteran is being admitted for.
Signature
87. DATE-Date VA Physician/ARNP or PA signed
Additional Information for completing the 10-10SH application…..
Answer all questions in the appropriate sections. If additional space is needed, write “Continuation of the Item” in that section and attach a sheet of
paper containing the Veteran's Name, Social Security Number and the section and question number from the form needing the additional information.

VA FORM
JUN 2015

10-10SH

PREVIOUS EDITIONS OF THIS FORM ARE NOT TO BE USED

PAGE 5 of 5