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: Before completing this form, read the Privacy Act and Respondent Burden on page
2. VA uses this form to determine eligibility for pension and aid and attendance benefits based on
nursing home status. For more information you can contact us online through Ask VA: https://ask.
va.gov, or call us toll-free at 1-800-827-1000 (TTY: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 checkbox to help expedite
processing of the form.
1. VETERAN'S NAME (First, Middle Initial, Last)

2. SOCIAL SECURITY NUMBER

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

3. VA FILE NUMBER

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)

6. SOCIAL SECURITY NUMBER

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

7. VA FILE NUMBER (If applicable)

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 (MM/DD/YYYY)

12. IS THE NURSING HOME A MEDICAID APPROVED FACILITY?
YES

13. HAS THE PATIENT APPLIED FOR MEDICAID?
YES

NO
14B. DATE MEDICAID PLAN BEGAN (MM/DD/YYYY)

14A. IS THE PATIENT COVERED BY MEDICAID?
YES

NO

NO

(If "YES," complete Item 14B)

15. MONTHLY AMOUNT PATIENT IS RESPONSIBLE FOR OUT OF POCKET $

,

.

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)

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

18. NURSING HOME OFFICIAL'S TITLE

Enter International Phone
Number (If applicable)

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 (MM/DD/YYYY)

20. SIGNATURE OF NURSING HOME OFFICIAL (REQUIRED)

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
XXX XXXX

21-0779

SUPERSEDES VA FORM 21-0779, AUG 2020.

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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 Veteran Readiness 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: VA needs this information to determine eligibility for pension and aid and attendance benefits based on nursing home status. 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, XXX XXXX

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