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

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

VA DATE STAMP

(Do Not Write In This Space)

INSTRUCTIONS: For free help in completing this form, call VA toll-free at 1-800-827-1000. (Hearing Impaired TDD
line 1-800-829-4833.)

Section I - IDENTIFICATION INFORMATION
1A. NAME OF NURSING HOME

1B. ADDRESS OF NURSING HOME

2. ADDRESS OF VA REGIONAL OFFICE

3. FIRST NAME - MIDDLE INITIAL- LAST NAME OF CLAIMANT

4. SOCIAL SECURITY NUMBER

5. VA FILE NUMBER

SECTION II - NURSING HOME INFORMATION (To be completed by a Nursing Home Official)
6. DATE ADMITTED TO NURSING HOME (Month, Day, Year)

7. DATE MEDICAID BEGAN (Month, Day, Year)

8. AMOUNT PATIENT IS RESPONSIBLE FOR OUT OF POCKET

$
9. 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

10. NURSING HOME OFFICIAL'S NAME (First & Last) (Please print)

11. NURSING HOME OFFICIAL'S TITLE (Please print)

12. NURSING HOME OFFICIAL'S OFFICE
TELEPHONE NUMBER (Include Area Code)

13A. SIGNATURE OF NURSING HOME OFFICIAL

13B. DATE SIGNED

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. Your obligation to respond is voluntary however 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 http://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
MAR 2010

21-0779

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