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

OMB Approved No: 2900-0652
Respondent Burden: 10 Minutes
Expiration Date: XXXXXXXXX

VA DATE STAMP

(Do Not Write In This Space)

REQUEST FOR NURSING HOME INFORMATION IN CONNECTION
WITH CLAIM FOR AID AND ATTENDANCE
INSTRUCTIONS: Before completing this form, read the Privacy Act and Respondent Burden. We use
this form to determine eligibility in connection with a claim for aid and attendance. For more
information, contact us at https://iris.custhelp.va.gov, or call us toll-free at 1-800-827-1000. If you
use a Telecommunications Device for the Deaf (TDD), the Federal relay number is 711. VA forms are
available at www.va.gov/vaforms. After completing the form, mail to: Department of Veterans
Affairs, Evidence Intake Center, P.O. Box 4444, Janesville, WI, 53547- 4444.
SECTION I - VETERAN'S IDENTIFICATION INFORMATION
NOTE: You may complete the form online or by hand. If completing by hand, print neatly and legibly in ink, and completely fill in each applicable circle to help expedite processing
of the form.
1. VETERAN'S NAME (First, Middle Initial, Last)

2. SOCIAL SECURITY NUMBER

4. DATE OF BIRTH

3. VA FILE NUMBER

Month

Day

Year

SECTION II - CLAIMANT'S IDENTIFICATION INFORMATION (Complete this section ONLY IF the claimant is NOT the veteran)
5. CLAIMANT'S NAME (First, Middle Initial, Last)

8. DATE OF BIRTH

7. VA FILE NUMBER (If applicable)

6. SOCIAL SECURITY NUMBER

Month

Day

Year

SECTION III - NURSING HOME INFORMATION
9. NAME OF NURSING HOME

10. 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 IV - GENERAL INFORMATION (To be completed by a Nursing Home Official)
NOTE: Your state's Medicaid program may use a different name.
11. DATE ADMITTED TO NURSING HOME
Month

Day

12. IS THE NURSING HOME A MEDICAID APPROVED FACILITY?

Year
YES

13. HAS THE PATIENT APPLIED FOR MEDICAID?
YES

NO

NO
14B. DATE MEDICAID PLAN BEGAN

14A. IS THE PATIENT COVERED BY MEDICAID?
YES

NO

15. MONTHLY AMOUNT PATIENT IS RESPONSIBLE FOR OUT OF POCKET

Month

Day

Year

(If "YES," complete Item 14B)

$

16. 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

17. NURSING HOME OFFICIAL'S NAME (First and Last) (Please print)

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

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

SECTION V - CERTIFICATION AND SIGNATURE
I CERTIFY THAT the statements on this form are true and correct to the best of my knowledge and belief.
21. DATE SIGNED
Month
Day

20. SIGNATURE OF NURSING HOME OFFICIAL (Sign in ink)

Year

PENALTY: The law provides severe penalties (including fine and/or imprisonment) for willfully submitting any statement or evidence of a material fact you know to be false, or for
fraudulent receipt of any document you are not entitled to.
VA FORM
XXXX

21-0779

SUPERSEDES VA FORM 21-0779, FEB 2017.

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 21-0779, XXXX

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