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pdfOMB Approval No. 2900-0160
Estimated Burden: Avg. 30 min.
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STATE HOME PROGRAM APPLICATION FOR VETERAN CARE
MEDICAL CERTIFICATION
PART I - ADMINISTRATIVE
STATE HOME FACILITY
DATE ADMITTED
GENDER
M
F
RESIDENT'S NAME (Last, First, Middle ) (This is a mandatory field)
SOCIAL SECURITY NUMBER. (Mandatory field)
RESIDENT'S STREET ADDRESS
AGE
CITY, STATE AND ZIP CODE
ADVANCED MEDICAL DIRECTIVE
DATE OF BIRTH (mm/dd/yyyy)
NO
YES
HAS THE VETERAN PROVIDED FINANCIAL DISCLOSURE FOR PURPOSES OF DETERMINING ELIGIBILITY FOR DOMILICIARY PER DIEM PAYMENTS?
YES
N/A
NO
10-10EZ or 10-10EZR IS REQUIRED TO BE SUBMITTED EITHER IN FPAPER FORM OR ELECTRONICALLY WITH THE 10-10SH
PART II - HISTORY AND PHYSICAL (Use separate sheet if necessary)
HISTORY
HEIGHT
WEIGHT
TEMP
PULSE
BP
HEAD/EYES/EAR/NOSE AND THROAT
NECK
CARDIOPULMONARY
ABDOMEN
GENITOURINARY
RECTAL
EXTREMITIES
NEUROLOGICAL
ALLERGY/DRUG SENSITIVITY
CHEST
X-RAY
X-RAY/
LAB
DATE (mm/dd/yyyy)
RESULTS
DATE (mm/dd/yyyy)
ALBUMEN
CBC
RESULTS
DATE (mm/dd/yyyy)
SEROLOGY
URINALYSIS
ACETONE
SUGAR
CHECK ALL BOXES THAT APPLY OR CHECK NA
IS DEMENTIA THE
PRIMARY DIAGNOSIS
YES
IS THERE A DIAGNOSIS OF MENTAL ILLNESS HAS RESIDENT RECEIVED MENTAL
SERVICES WITHIN THE PAST 2 YEARS
YES
N/A
NO
NO
N/A
IS THERE ANY PRESSING EVIDENCE OF MENTAL ILLNESS SUCH AS:
PARANOIA
SCHIZOPHRENIA
SOMATOFORM DISORDER
MOOD SWINGS
YES
N/A
NO
IS CLIENT A DANGER TO SELF OR
OTHERS
YES
NO
N/A
OTHER PSYCHOTIC OR MENTAL DISORDERS LEADING TO CHRONIC DISABILITY
PANIC OR SEVERE ANXIETY DISORDER
PERSONALITY DISORDER
TUBE FEEDING
DECUBITUS ULCERS
MASK
PRN
OSTOMY
DRAINING WOUND
TEMPORARY
NASAL CANULAR
CONTINUOUS
TRACHOSTOMY
WOUND CULTURED
PERMANENT
OXYGEN
REFERRING PHYSICIAN
PRIMARY DIAGNOSIS
SECONDARY DIAGNOSIS
TERTIARY DIAGNOSIS
ARE THE ADMITTING DIAGNOSIS RELATED TO A SERVICE CONNECTED CONDITION?
TYPE OF CARE RECOMMENDED:
SKILLED NURSING HOME CARE
YES
FOLEY CATHETER
NO
DOMICILIARY CARE
ADULT HEALTH CARE
MEDICATION AND TREATMENT ORDERS ON ADMISSION, CONTINUE ON SEPARATE SHEET IF NECESSARY
PRINTED OR TYPED NAME OF PRIMARY PHYSICIAN ASSIGNED
VA FORM
MAY 2015
10-10SH
SIGNATURE OF PRIMARY PHYSICIAN ASSIGNED
PREVIOUS EDITIONS OF THIS FORM ARE NOT TO BE USED
PAGE 1
STATE HOME PROGRAM APPLICATION FOR VETERAN CARE - MEDICAL CERTIFICATION, CONTINUED
RESIDENT'S NAME (Last, First, Middle )
SOCIAL SECURITY NUMBER
EVALUATION (Select an appropriate number in each category)
COMMUNICATION
1. Transmits messages/receives information
2. Limited ability
3. Nearly or totaly unable
SPEECH
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
1. Good
2. Hearing slightly impaired
3. Nearly or totaly unable
4. Virtually/completely deaf
HEARING
TRANSFER
ENDURANCE
1. No assistance
2. Equipment only
3. Supervision only
4. Requires human transfer w/wo equipment
5. Bedfast
AMBULATION
1. Independence w/wo assistive device
2. Walks with supervision
3. Walks with continuous human support
4. Bed to chair (total help)
5. Bedfast
1. Tolerates distances (250 feet sustained activity)
2. Needs intermitten rest
3. Rarely tolerates short activities
4. No tolerance
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
1. No assistance
2. Assistance to and from
and transfer
3. Total assistance including
personal hygiene,
help with clothes
TOILETING
A. Bathroom
B. Bedside
commode
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
1. Intact
2. Dry/Fragile
3. Irritations (Rash)
4. Open wound
5. Decubitus
SKIN
CONDITION
BATHING
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
WHEEL CHAIR
USE
Stage
2. Assistance in difficult maneuvering
3. Wheels a few feet
4. Unable to use
NA
DATE
SIGNATURE OF REGISTERED NURSE OR REFERRING PHYSICIAN
PHYSICAL THERAPY (To be completed by Physical Therapist or Referring Physician)
SENSATION IMPAIRED RESTRICT ACTIVITY
YES
NO
YES
NEW REFERRAL
CONTINUATION
PRECAUTIONS
NO
CARDIAC
N/A
FREQUENCY OF TREATMENT
OTHER
(Specify)
ACTIVE
COORDINATING ACTIVITIES
FULL WEIGHT BEARING
WHEELCHAIR INDEPENDENT
STRETCHING
ACTIVE ASSISTIVE
NON-WEIGHT BEARING
PROGRESS BED TO WHEELCHAIR
COMPLETE AMBULATION
PASSIVE ROM
PROGRESSIVE RESISTIVE
PARTIAL WEIGHT BEARING
RECOVERY TO FULL FUNCTION
TREATMENT GOALS:
SIGNATURE OF AND TITLE OF THERAPIST OR REFERRING PHYSICIAN
ADDITIONAL THERAPIES
O.T.
SPEECH
DATE
DIETARY
SOCIAL WORK ASSESSMENT (To be completed by Social Worker)
PRIOR LIVING ARRANGEMENTS
LONG RANGE PLAN
ADJUSTMENT TO ILLNESS OR DISABILITY
SIGNATURE OF SOCIAL WORKER
VA FORM
MAY 2015
10-10SH
DATE
PREVIOUS EDITIONS OF THIS FORM ARE NOT TO BE USED
PAGE 2
OMB Approval No. 2900-0160
Estimated Burden: Avg. 30 min.
PART III VA AUTHORIZATION FOR PAYMENT
CLINICAL REVIEW
ADMINISTRATIVE REVIEW
SERVICE CONNECTED CONDITION BEING ADMITTED FOR:
10-10EZ or 10-10EZR RECEIVED WITH 10-10SH:
YES
ELECTRONIC VERSION
NO
IS VETERAN BEING ADMITTED DUE TO SC CONDITION:
(IF LESS THAN 70%)
NURSING HOME CARE
SERVICE CONNECTED CONDITION RATING GREATER OR EQUAL TO 70%:
YES
YES
NO
NO
YES
NO
DOMICILIARY CARE
DOES THE VETERAN HAVE MEANS TO PROVIDE FOR SELF OR
PROVIDED FOR IN THE COMMUNITY:
ELIGIBLE FOR PER DIEM PAYMENT NURSING HOME CARE:
YES
YES
VETERAN APPROVED FOR NURSING HOME LEVEL OF CARE:
NO
DOES VETERAN HAVE A RATING OF TOTAL DISABILITY BASED ON INIDIVIDUAL
UNEMPLOYABILITY:
YES
NO
NO
DOES HEALTH AND/OR FUNCTIONAL DEFICITS RENDER VETERAN
UNABLE OF PURSUING SUBSTANIALLY GAINFUL EMPLOYMENT:
APPROVED PER DIEM RATE:
BASIC
NURSING HOME CARE
Date Received by VA:
Date Admitted to SVH:
YES
PREVAILING RATE
NO
VETERAN APPROVED FOR DOMICILIARY LEVEL OF CARE:
ADULT DAY HEALTH CARE
YES
ELIGIBLE FOR PER DIEM PAYMENT FOR ADULT DAY HEALTH CARE:
YES
NO
ADULT DAY HEALTH CARE
IF NOT ENROLLED IN ADHC, WILL VETERAN REQUIRE NURSING
HOME CARE: (38 U.S.C. 1720)(F)(1)(A))
DOMICILIARY CARE
DOES INCOME EXCEED THRESHOLD FOR AID & ATTENDANCE:
YES
NO
YES
ELIGIBLE FOR PER DIEM PAYMENT DOMICILIARY CARE:
YES
NO
VETERAN APPROVED FOR ADULT DAY HEALTH CARE:
NO, ADDITIONAL ELIGIBILITY REQUIREMENTS
VA ADMINISTRATIVE SIGNATURE
NO
YES
NO
DATE
REMARKS:
REMARKS:
SIGNATURE OF VA PHYSICIAN/ANRP/PA
DATE
PAPERWORK REDUCTION ACT AND PRIVACY ACT NOTICE
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 30 minutes. This includes the time it will take to read
instructions, gather the necessary facts and fill out the form. 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
MAY 2015
10-10SH
PREVIOUS EDITIONS OF THIS FORM ARE NOT TO BE USED
PAGE 3
INSTRUCTION SHEET
STATE HOME PROGRAM APPLICATION FOR VETERAN CARE MEDICAL
CERTIFICATION
VA FORM 10-10SH
This form should take an average of 30 minutes to complete
1. USE OF VA FORM 10-10SH, 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 101-10EZR,
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).
2. GENERAL INSTRUCTIONS
Part I (Administrative) and Part II (History and Physical) of the 10-10SH form 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.
____________________________________________________________________
Part III – VA Authorization for Payment is completed in full by VA Medical Center of Jurisdiction designated staff.
ADMINISTRATIVE REVIEW SECTION
a. 10-10EZ or 10-10EZR Has Been Received with 10-10SH. Check the appropriate if the forms were received with
the 10-10SH or if the forms were completed electronically.
b. Date Admitted To SVH. Enter the date the Veteran was physically admitted to the facility.
c. Date Received By VA. Enter the date the complete admissions application was received by the VA.
Nursing Home Care
d. Service Connected Condition Rating Greater or Equal to 70%. Check the appropriate answer YES or NO if the
Veteran is 70% SC.
e. Does the Veteran Have a Rating of Total Disability Based on Individual employability? Check the appropriate
response, YES or NO.
f. Eligible for Per DIEM Payment Nursing Home Care. Check the appropriate answer, YES or NO
g. Approved Per DIEM Rate. Check either, Basic or the Prevailing rate.
Adult Day Health Care
h. Eligible for Per DIEM Payment for Adult Day Health Care. Check the appropriate answer, YES or NO.
i. Service Connected Condition Rating. Indicate the appropriate service connected rating if any for the Veteran
being admitted to the SVH.
j. Approval For Per DIEM Payment. Indicate the approval decision.
k. Approved Per Diem Rate. Indicate the rate methodology, basic, higher or prevailing.
Domiciliary Care
l. Does Income Exceed Threshold For Aid & Attendance? Indicate if the Veterans annual income exceeds the
maximum amount of someone in receipt of Aid & Attendance for the following categories; Single Veteran, Veteran
with Spouse/Dependent, Two Veterans Married to Each Other, Surviving Spouse, or Surviving Spouse with One
Dependent.
m. VA Administrative Signature. Sign and date when the administrative review was completed.
CLINICAL REVIEW SECTON
Is the Veteran being admitted for a service connected (SC) condition, it is important for the reviewing clinician to
determine if the primary, secondary or tertiary diagnoses are service related and are the reasons the Veteran
needs Nursing Home care as this determination affects per diem payments. If the reason for being admitted to the
nursing home is a SC connected condition, identify the SC condition in the space provided.
Nursing Home Care
a. Is the Veteran Being Admitted Due to Service Connected Condition (if less than 70%). Check the appropriate
answer, YES or NO.
b. Service Connected Condition Being Admitted For. Enter the service connected condition the Veteran is being
admitted for.
c. Veteran Approved for Nursing Home Level of Care. Check the appropriate answer, YES or NO.
Domiciliary Care
c. Does the Veteran Have Means to Provide for Self or Provided for in the Community? Check the appropriate
answer, YES or NO. When evaluating this question in addition to considering the Veterans annual income their
wealth / assets also factor into the decision. If the Veteran has a lot of wealth /assets, the Veteran should be
evaluated to determine if they have the means to provide adequately for self as it relates to finances.
d. Does Health and or Functional Deficits Render Veteran Unable of Pursuing Substantially Gainful Employment?
Check the appropriate answer, YES or NO.
If the Chief of Staff or designee makes the determination the Veteran is unable to pursue substantially gainful
employment and the clinical provider reviewing the application determines the Veteran has health and functioning
deficits that require the placement in the SVH and the Veteran is capable of performing the following daily living
activities:
(1) Perform without assistance daily adulations, such as brushing teeth, bathing, combing hair, and body
eliminations.
(2) Dress self, with minimum of assistance.
(3) Proceed to and return from the dining hall without aid.
(4) Feed self.
(5) Secure medical attention on an ambulatory basis by use of personally propelled wheelchair.
(6) Have voluntary control over body eliminations or control by use of an appropriate prosthesis.
(7) Share in some measure, however slight, in the maintenance and operation of the facility.
(8) Mark rational and competent decisions as to his or her desire to remain or leave the facility.
If all the above conditions are met, check "Yes" in the appropriate box. If these conditions are not met, check "No".
If any of the above questions are answered "No", per diem is not approved.
e. Veteran approved for Domiciliary Level of Care. Check the appropriate answer, YES or NO.
Adult Day Health Care
f. If Not Enrolled in ADHC, Will the Veteran Require Nursing Home Care? Check the appropriate answer, YES or
NO.
d. Signature Of VA Physician/ARNP or PA and Date. Sign and date when the clinical review is completed.
Additional Information for completing the 10-10SH application…..
Answer all questions in the appropriate sections. If you need more space to answer a question, please attach a
sheet of paper to the form containing the Veteran’s name and Social Security Number. If you need more room to
respond to a question, write “Continuation of Item” and write the section and question number.
| File Type | application/pdf |
| File Title | 10-10SH-fill(3.2).pdf |
| Author | Cynthia |
| File Modified | 2015-05-18 |
| File Created | 2015-05-18 |