Form VA Form 21-0779 VA Form 21-0779 Request for Nursing Home Information in Connection with

OMB Approved No: 2900-0652
Respondent Burden: 10 Minutes
Expiration Date: XX/XX/XXXX

VA DATE STAMP

(Do Not Write In This Space)

REQUEST FOR NURSING HOME INFORMATION IN CONNECTION
WITH CLAIM FOR AID AND ATTENDANCE
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)

Section I - VETERAN/CLAIMANT'S IDENTIFICATION INFORMATION
NOTE: You can either complete the form online or by hand. Please print the information requested in ink, neatly, and legibly to help process the form.
1. VETERAN/CLAIMANT'S NAME (First, Middle, Last)

2. VETERAN/CLAIMANT'S SOCIAL SECURITY NUMBER

4. VETERAN'S DATE OF BIRTH (MM/DD/YYYY)

3. VA FILE NUMBER

Month

Day

Year

5. VETERAN'S SERVICE NUMBER (If applicable)

SECTION II - NURSING HOME INFORMATION
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
Country

State/Province

ZIP Code/Postal Code

SECTION III - GENERAL INFORMATION (To be completed by a Nursing Home Official)
9. IS THE NURSING HOME FACILITY MEDICAID OR EQUIVALENT APPROVED?

8. DATE ADMITTED TO NURSING HOME (MM/DD/YYYY)
Month

Day

Year
YES

10. HAS THE PATIENT APPLIED FOR MEDICAID?
YES

NO

NO

11A. IS THE PATIENT COVERED BY MEDICAID OR
EQUIVALENT PLAN?
YES

NO

11B. DATE MEDICAID OR EQUIVALENT PLAN BEGAN
Month

Day

Year

(If "Yes," complete Item 11B)

12. MONTHLY AMOUNT PATIENT IS RESPONSIBLE FOR OUT OF POCKET

$
13. I CERTIFY THAT THE CLAIMANT IS A PATIENT IN THIS FACILITY BECAUSE OF MENTAL OR PHYSICAL DISABILITY AND IS RECEIVING: (Check one)
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
I CERTIFY THAT the statements on this form are true and correct to the best of my knowledge and belief.
17. SIGNATURE OF NURSING HOME OFFICIAL

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.
VA FORM
SUPERSEDES VA FORM 21-0779, MAR 2004,
21-0779
XXX XXXX
WHICH WILL NOT BE USED.