Form 10-10SH State Homes Program Application for Veterans Care Medica

OMB Control No: 2900-0160
Estimated Burden: 20 minutes
Expiration Date: 10-31-2023

STATE HOME PROGRAM APPLICATION FOR VETERAN
CARE MEDICAL CERTIFICATION
PART I - ADMINISTRATIVE

2. DATE ADMITTED (MM/DD/YYYY)

1. STATE HOME FACILITY
3. STATE HOME FACILITY ADDRESS (Street, City, State and Zip Code)
4. RESIDENT'S NAME (Last, First, Middle)
5. SOCIAL SECURITY NUMBER

6. GENDER
M

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

7. AGE

9. ADVANCED MEDICAL DIRECTIVE
NO

F

YES

10. HAS THE VETERAN PROVIDED FINANCIAL DISCLOSURE FOR PURPOSES OF DETERMINING ELIGIBILITY FOR DOMICILIARY PER DIEM PAYMENTS?
YES

NO

N/A

10-10EZ or 10-10EZR IS REQUIRED TO BE SUBMITTED EITHER IN PAPER FORM OR ELECTRONICALLY WITH THE 10-10SH

PART II - HISTORY AND PHYSICAL (Use separate sheet if necessary)
11. HISTORY

12. HEIGHT

13. WEIGHT

14. TEMP

15. PULSE

16. BP

17. HEAD/EYES/EAR/NOSE AND THROAT

18. NECK

19. CARDIOPULMONARY

20. ABDOMEN

21. GENITOURINARY

22. RECTAL

23. EXTREMITIES

24. NEUROLOGICAL

25. ALLERGY/DRUG SENSITIVITY
DATE (MM/DD/YYYY)

CHEST
X-RAY

26.
X-RAY/ SEROLOGY
LAB
URINALYSIS

RESULT

N/A

DATE (MM/DD/YYYY)

CBC

RESULT

N/A
N/A

DATE (MM/DD/YYYY)

ALBUMIN

ACETONE

SUGAR

N/A

CHECK ALL BOXES THAT APPLY OR CHECK N/A
27. IS DEMENTIA THE
PRIMARY DIAGNOSIS
YES

NO

28. IS THERE A DIAGNOSIS
OF MENTAL ILLNESS

N/A

YES

NO

29. HAS RESIDENT RECEIVED MENTAL HEALTH
SERVICES WITHIN THE PAST 2 YEARS

N/A

YES

NO

30. IS CLIENT A DANGER TO SELF OR OTHERS

N/A

YES

NO

N/A

31. IS THERE ANY PRESSING EVIDENCE OF MENTAL ILLNESS SUCH AS:
SCHIZOPHRENIA

PARANOIA

OTHER PSYCHOTIC OR MENTAL DISORDERS LEADING TO CHRONIC DISABILITY

MOOD SWINGS

SOMATOFORM DISORDER

PANIC OR SEVERE ANXIETY DISORDER

33. FEEDING

32. OXYGEN
MASK

PRN

NASAL CANNULA

PERSONALITY DISORDER

34. WOUND

N/A

35. FOLEY CATHETER

CONTINUOUS

TUBE FEEDING

OSTOMY

DECUBITUS ULCERS

DRAINING WOUND

TEMPORARY

N/A

TRACHEOSTOMY

N/A

WOUND CULTURED

N/A

PERMANENT

36. REFERRING PHYSICIAN

37. PRIMARY DIAGNOSIS

38. SECONDARY DIAGNOSIS

39. TERTIARY DIAGNOSIS

40. ARE THE ADMITTING DIAGNOSIS RELATED TO A SERVICE CONNECTED CONDITION?
41. TYPE OF CARE RECOMMENDED:

SKILLED NURSING HOME CARE

YES

NO

DOMICILIARY CARE

N/A

UNKNOWN
ADULT DAY HEALTH CARE

42. MEDICATION AND TREATMENT ORDERS ON ADMISSION, CONTINUE ON SEPARATE SHEET IF NECESSARY

43. PRINTED OR TYPED NAME OF SVH PHYSICIAN/APRN/PA

VA FORM
AUG 2023

10-10SH

44. SIGNATURE OF SVH PHYSICIAN/APRN/PA

PREVIOUS EDITIONS OF THIS FORM ARE NOT TO BE USED

NOTE: This field cannot be signed without
first filling out item numbers 36 through 43.
After signing, all fields in Part 2 will become
locked and read only.
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STATE HOME PROGRAM APPLICATION FOR VETERAN CARE MEDICAL CERTIFICATION
PART III - EVALUATION (Select an appropriate number in each category)
45. RESIDENT'S NAME (Last, First, Middle)

46. SOCIAL SECURITY NUMBER

1. Transmits messages/receives information

COMMUNICATION

1. Speaks clearly with others of same language

SPEECH

2. Limited ability

3. Unable to speak clearly or not at all

1. Good

1. Good

2. Hearing slightly impaired

HEARING

2. Limited ability

3. Nearly or totally unable

2. Vision adequate - Unable to read/see details

SIGHT

3. Nearly or totally unable

3. Vision limited - Gross object differentiation

4. Virtually/completely deaf

4. Blind

1. No assistance

1. Independence w/wo assistive device

2. Equipment only

TRANSFER

2. Walks with supervision

AMBULATION

3. Supervision only

3. Walks with continuous human support

4. Requires human transfer w/wo equipment

4. Bed to chair (total help)

5. Bedfast

5. Bedfast

1. Tolerates distances (250 feet sustained activity)

1. Alert

A. Agreeable

2. Confused

B. Disruptive

3. Disoriented

C. Apathetic

4. Comatose

D. Well motivated

1. No assistance

A. Tub

2. Supervision Only

B. Shower

3. Assistance

C. Sponge bath

MENTAL AND
BEHAVIOR
STATUS

2. Needs intermittent rest

ENDURANCE

3. Rarely tolerates short activities
4. No tolerance
1. No assistance
2. Assistance to and from
transfer

TOILETING

A. Bathroom

BATHING

B. Bedside
commode

3. Total assistance including
personal hygiene,
help with clothes

4. Is bathed

C. Bedpan

1. Dresses self

1. No assistance

2. Minor assistance

DRESSING

2. Minor assistance, needs tray set up only

FEEDING

3. Needs help to complete dressing

3. Help feeding/encouraging

4. Has to be dressed

4. Is fed

1. Continent

1. Continent

2. Rarely incontinent

2. Rarely incontinent

3. Occasional - once/week or less

BLADDER
CONTROL

3. Occasional - once/week or less

BOWEL
CONTROL

4. Frequent - up to once a day

4. Frequent - up to once a day

5. Total incontinence

5. Total incontinence

6. Catheter, indwelling
1. Intact

SKIN
CONDITION

6. Ostomy
5. Decubitus

2. Dry/Fragile

Number

3. Irritations (Rash)

Stage

4. Open wound

NOTE: Number &
Stage fields will
become available
only when #2
through 5 are
selected.

1. Independence

WHEEL CHAIR
USE

NO

51. RESTRICT ACTIVITY
YES

52. PRECAUTIONS

NO

CARDIAC

N/A

NOTE: After signing, all
fields in Part 3 will become
locked and read only.

PHYSICAL THERAPY (To be completed by Physical Therapist or Physician/APRN/PA) 49. Check if
YES

3. Wheels a few feet
4. Unable to use

47. SIGNATURE OF REGISTERED NURSE OR PHYSICIAN/APRN/PA

50. SENSATION IMPAIRED

2. Assistance in difficult maneuvering

OTHER

NEW REFERRAL

48. DATE(MM/DD/YYYY)

CONTINUATION OF THERAPY

(Type
other,
specify)

N/A

53. FREQUENCY OF TREATMENT

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

54. TREATMENT GOALS:

56. SIGNATURE OF AND TITLE OF THERAPIST OR PHYSICIAN/APRN/PA NOTE: After signing, all

55. ADDITIONAL THERAPIES
O.T.

SPEECH

fields under Physical
Therapy will become
locked and read only.

DIETARY

57. DATE (MM/DD/YYYY)

PART IV - SOCIAL WORK ASSESSMENT (To be completed by SVH Social Worker (SW) or Physician/APRN/PA)
58. PRIOR LIVING ARRANGEMENTS

59. LONG RANGE PLAN

60. ADJUSTMENT TO ILLNESS OR DISABILITY, LIVING ENVIRONMENT AND MAKE COMPETENT DECISIONS
62. SIGNATURE OF SW OR PHYSICIAN/APRN/PA

61. PRINT NAME OF SW OR PHYSICIAN/APRN/PA

NOTE: After signing, all fields
in Part 4 will become locked and
read only.

63. DATE (MM/DD/YYYY)

64. REMARKS (Attach additional sheets if necessary)

VA FORM 10-10SH, AUG 2023

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STATE HOME PROGRAM APPLICATION FOR VETERAN CARE MEDICAL CERTIFICATION
PART V - VA AUTHORIZATION FOR PAYMENT
65. RESIDENT'S NAME (Last, First, Middle)

66. SOCIAL SECURITY NUMBER

ADMINISTRATIVE REVIEW

CLINICAL REVIEW

67. 10-10EZ OR 10-10EZR HAS BEEN RECEIVED WITH 10-10SH:
YES

NO

N/A (ELECTRONIC VERSION COMPLETED)

68. DATE ADMITTED TO SVH
(MM/DD/YYYY):

69. DATE RECEIVED BY VA
(MM/DD/YYYY):

74. IS VETERAN BEING ADMITTED DUE TO SC CONDITION?
YES

NO

75. SERVICE CONNECTED CONDITION BEING ADMITTED FOR:

70. VETERAN ELIGIBLE FOR PER DIEM PAYMENT:
BASIC

PREVAILING

NO

NURSING HOME CARE

71. REMARKS (Attach additional sheets if necessary):

76. VETERAN APPROVED FOR NURSING HOME LEVEL OF CARE:
YES

NO
DOMICILIARY CARE (See Instructions for Clarification)

77. DOES VETERAN HAVE "NO ADEQUATE MEANS OF SUPPORT"?
YES

NO

(If checked yes, qualifies Veteran for per diem payment)

78. VETERAN APPROVED FOR DOMICILIARY LEVEL OF CARE:
YES

NO

(If checked yes, Veteran must meet all eight ADLs)

ADULT DAY HEALTH CARE (See Instructions for Clarification)
79. IF NOT ENROLLED IN ADHC, WILL VETERAN REQUIRE NURSING HOME
CARE?
YES

NO

80. VETERAN APPROVED FOR ADULT DAY HEALTH CARE:
YES

NO

81. REMARKS:

72. SIGNATURE OF VA ADMINISTRATIVE REVIEWER

73. DATE

(MM/DD/YYYY)

NOTE: After signing, all fields in Part 5, Administrative Review will become
locked and read only.

82. SIGNATURE OF VA PHYSICIAN/APRN/PA

83. DATE

(MM/DD/YYYY)

NOTE: After signing, all fields in Part 5, Clinical Review, Nursing Home Care,
Domiciliary Care, and Adult Day Health Care will become locked and read only.

PAPERWORK REDUCTION ACT OF 1995 AND PRIVACY ACT STATEMENT
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 who must complete this form will average 20 minutes. This includes the time it will
take to read instructions, gather the necessary facts and fill out the form.
Privacy Act Information: The information requested on this form is solicited under the authority of Title 38, U.S.C. Sections 1741, 1743 and 1745. It is
being collected to enable us to determine eligibility for health benefits in the State Home Program and will be used for that purpose. The information 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. VA may
make a "routine use" disclosure of the information as outlined in the Privacy Act systems of records notices and in accordance with the VHA Notice of
Privacy Practices. Providing the requested information is voluntary, but if any or all the requested information is not provided, it may delay or result in denial
of your request for health care benefits. Failure to furnish the information will not have any effect on any other benefits to which the Veteran may be entitled.
The disclosure of Social Security Number; VA will use it to administer VA benefits. VA may also use this information to identify Veterans and persons
claiming or receiving VA benefits and their records, and for other purposes authorized or required by law.

VA FORM 10-10SH, AUG 2023

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VA FORM 10-10SH - INSTRUCTIONS
As a condition for VA approved State Veterans Home (SVH) to 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 10-10EZR, Health Benefits Update Form. Use additional sheets if needed 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.
PART I - ADMINISTRATIVE
This section must be completed in full by State Veterans Home designated staff.
1. STATE HOME FACILITY - Enter the name of the facility
2. DATE ADMITTED - Select the date admitted using the calendar or enter
the date as MM/DD/YYYY
3. STATE HOME FACILITY ADDRESS - Enter complete address
4. RESIDENT'S NAME - Enter the full name of the person to whom this
application applies
5. SOCIAL SECURITY NUMBER - Enter the full social security number of
the applicant

6. GENDER - Check the appropriate box
7. AGE - Age of applicant
8. DATE OF BIRTH - Enter the date of birth in the format MM/DD/YYYY
9. ADVANCED MEDICAL DIRECTIVE - Check No or Yes
10. HAS THE VETERAN PROVIDED FINANCIAL DISCLOSURE FOR
PURPOSES OF DETERMINING ELIGIBILITY FOR DOMICILIARY PER
DIEM PAYMENTS? Check Yes, No, or N/A.
10-10EZ or 10-10EZR is required to be submitted either in paper
form or electronically with the 10-10SH. Note: N/A is used for
admission application for NHC and ADHC.

PART II - HISTORY AND PHYSICAL
This section 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.
11.
12.
13.
14.
15.
16.

HISTORY - Enter the patient background and history
HEIGHT - Enter the applicant's height
WEIGHT - Enter the applicant's weight
TEMP - Enter the applicant's temperature
PULSE - Enter the applicant's pulse rate
BP - Enter the applicant's blood pressure

17. HEAD/EYES/EARS/NOSE AND THROAT - Enter any problems with
the head, eyes, ears, nose and throat or N/A
18. NECK - Enter any problems with the neck or N/A
19. CARDIOPULMONARY - Enter any problems with the heart or N/A
20. ABDOMEN - Enter any problems with the abdomen or N/A
21. GENITOURINARY - Enter any problems with the genitourinary system
or N/A
22. RECTAL - Enter any problems with the rectum or N/A
23. EXTREMITIES - Enter any problems with the extremities or N/A
24. NEUROLOGICAL - Enter any problems neurologically or N/A
25. ALLERGY/DRUG SENSITIVITY - Enter any allergies or sensitivities or
N/A
26. X-RAY/LAB - Date of chest x-ray, results; CBC date, result; serology;
urinalysis date, albumin, sugar, acetone or N/A
27. IS DEMENTIA THE PRIMARY DIAGNOSIS? Check Yes, No or N/A
(not applicable)
28. IS THERE A DIAGNOSIS OF MENTAL ILLNESS? Check Yes, No or
N/A (not applicable)

29. HAS THE RESIDENT RECEIVED MENTAL SERVICES WITHIN
THE PAST 2 YEARS? Check Yes, No or N/A (not applicable)
30. IS CLIENT A DANGER TO SELF OR OTHERS? Check Yes, No or
N/A (not applicable)
31. IS THERE ANY PRESSING EVIDENCE OR MENTAL ILLNESS
SUCH AS - Check all that apply or check N/A
32.
33.
34.
35.
36.
37.

OXYGEN - Check all that apply or check N/A
FEEDING - Check all that apply or check N/A
WOUND - Check all that apply or check N/A
FOLEY CATHETER - Check all that apply or check N/A
REFERRING PHYSICIAN - Enter the name of the referring physician
PRIMARY DIAGNOSIS - Enter the primary diagnosis

38. SECONDARY DIAGNOSIS - Enter the secondary diagnosis
39. TERTIARY DIAGNOSIS - Enter the tertiary diagnosis
40. ARE THE ADMITTING DIAGNOSIS RELATED TO A SERVICE
CONNECTED CONDITION? Check Yes, No or Unknown
41. TYPE OF CARE RECOMMENDED - Choose the appropriate care
42. MEDICATION AND TREATMENT ORDERS ON ADMISSION,
CONTINUE ON SEPARATE SHEET IF NECESSARY - Enter all
medications and treatment orders on the applicant.
43. PRINTED OR TYPED NAME OF SVH PHYSICIAN/APRN/PA - Print or
Type name of SVH Physician, or Advanced Practice Registered Nurse
(APRN), or Physician Assistant (PA)
44. SIGNATURE OF SVH PHYSICIAN/APRN/PA - Enter signature

PART III - EVALUATION (To be completed by SVH)
45. RESIDENT'S NAME - Enter the full name of the person in which this
application applies
46. SOCIAL SECURITY NUMBER - Enter the full social security number of
the applicant
47. SIGNATURE OF REGISTERED NURSE OR PHYSICIAN/APRN/PA Enter signature
48. DATE - Enter date signed by registered nurse or Physician/APRN/PA
PHYSICAL THERAPY
49. Check the box if new or continued therapy or N/A
50. SENSATION IMPAIRED? Check Yes or No

VA FORM 10-10SH, AUG 2023

51. RESTRICT ACTIVITY? Check Yes or No
52. PRECAUTIONS - Check if there is a cardiac or other (for other type
over the text in the box)
53. FREQUENCY OF TREATMENT - Enter how often the applicant
receives physical therapy
54. TREATMENT GOALS - Check all that apply
55. ADDITIONAL THERAPIES - Check all that apply
56. SIGNATURE AND TITLE OF THERAPIST OR PHYSICIAN/APRN/PA Enter signature
57. DATE - Enter the date the Therapist or Physician signed (format
MM/DD/YYYY)

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VA FORM 10-10SH - INSTRUCTIONS
PART IV - SOCIAL WORK ASSESSMENT (To be completed by SVH Social Worker (SW) or Physician/APRN/PA)
58. PRIOR LIVING ARRANGEMENTS
59. LONG RANGE PLAN

61. PRINT NAME OF SW OR PHYSICIAN/APRN/PA - Print or type name
of Social Worker (SW) or Physician/APRN/PA

60. ADJUSTMENT TO ILLNESS OR DISABILITY, LIVING ENVIRONMENT
AND MAKE COMPETENT DECISIONS - Explain Veteran's ability to
adjust to their illness/disability, living environment and make competent
decisions

62. SIGNATURE OF SW OR PHYSICIAN/APRN/PA - Enter signature
63. DATE
64. REMARKS

PART V - VA AUTHORIZATION FOR PAYMENT
Completed in full by VA Medical Center of Jurisdiction designated staff
65. RESIDENT'S NAME - Enter the full name of the person in which this
application applies

78. VETERAN APPROVED FOR DOMICILIARY LEVEL OF CARE - Is
Veteran capable of performing the following daily living activities?

66. SOCIAL SECURITY NUMBER - Enter the full social security number of
the applicant

(1) Perform without assistance daily adulations, such as brushing
teeth, bathing, combing hair, and body eliminations.

ADMINISTRATIVE REVIEW SECTION

(2) Dress self, with minimum of assistance.
(3) Proceed to and return from the dining hall without aid.
(4) Feed self.

67. 10-10EZ OR 10-10EZR RECIEVED WITH 10-10SH - Check the
appropriate if the forms were received with the 10-10SH or if the forms
were completed electronically.
68. DATE ADMITTED TO SVH - Enter the date the Veteran was physically
admitted to the State Veteran's Home
69. DATE RECEIVED BY VA - Enter the date the complete admission
application was received by the VA.
70. VETERAN ELIGIBLE FOR PER DIEM PAYMENT - Check either Basic
or Prevailing for eligible Veteran; or No if not eligible. Veteran is eligible
if they are not barred from receiving VA pension, compensation or
dependency and indemnity compensation based on the character of a
discharge from military service. For Domiciliary Care, Veteran's income
from the 10-10EZ must meet the Aid and Attendance threshold or
determination for Domiciliary Care is made by Clinical Reviewer. For
ADHC, Veteran must be enrolled in the VA health care system at the
time of the application.
71. REMARKS - Enter any remarks regarding Administrative Review
section. If Veteran is not eligible, enter reason per diem is denied.
72. SIGNATURE OF VA ADMINISTRATIVE REVIEWER - Enter signature.
73. DATE - Date of Administrative Reviewer's signature.
CLINICAL REVIEW SECTION
74. IS VETERAN BEING ADMITTED DUE TO SC CONDITION? Check
YES or NO.
75. SERVICE CONNECTED CONDITION BEING ADMITTED FOR - If
necessary, review VA databases such as VISTA, HINQ, VIS, VBMS, or
CPRS for Veteran's service-connection condition/rating. If the reason
the Veteran is being admitted for nursing home or adult day health care
for a SC condition, enter the service-connected condition the Veteran is
being admitted for.
NURSING HOME CARE

(5) Secure medical attention on an ambulatory basis or by use of
personally propelled wheelchair.
(6) Have voluntary control over body eliminations or control by use of
an appropriate prosthesis.
(7) Participate in some measure, however slight, in work assignments
that support the maintenance and operation of the State home.
(8) Make 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.
ADULT DAY HEALTH CARE
79. IF NOT ENROLLED IN ADHC, WILL VETERAN REQUIRE NURSING
HOME CARE? Check YES or NO. Would Veteran require nursing
home care and need adult day health care; and must meet any one of
the following conditions:
(1) The veteran has three or more Activities of Daily Living (ADL)
dependencies.
(2) The veteran has significant cognitive impairment.
(3) The veteran has two ADL dependencies and two or more of the
following conditions: (i) Seventy-five years old or older; (ii) High use
of medical services, i.e., three or more hospitalizations per calendar
year, or 12 or more visits to an outpatient clinic or to an emergency
evaluation unit per calendar year; (iii) Diagnosis of clinical
depression; or (iv) Living alone in the community.
(4) The veteran does not meet the criteria in 38 CFR 51.52, but
nevertheless a licensed VA medical practitioner determines the
veteran needs adult day health care services.

76. VETERAN APPROVED FOR NURSING HOME LEVEL OF CARE Check YES or NO.

80. VETERAN APPROVED FOR ADULT DAY HEALTH CARE - Check
YES or NO.

DOMICILIARY CARE

81. REMARKS - Enter any remarks regarding Clinical Review section to
include justification for per diem denial.

77. DOES VETERAN HAVE "NO ADEQUATE MEANS OF SUPPORT" For purposes of domiciliary care, “no adequate means of support”
refers to an applicant whose annual income exceeds the rate of
pension described in 38 CFR 51.51, but who is able to demonstrate to
VA medical authority, on the basis of objective evidence, that deficits in
health or functional status render the applicant incapable of pursuing
substantially gainful employment, and who is otherwise without the
means to provide adequately for himself or herself, or be provided for in
the community. Check “Yes” for Veteran who has deficits in health or
functional status rendering the applicant incapable of pursuing
substantially gainful employment, and who is otherwise without the
means to provide adequately for himself or herself, or be provided for in
the community. Check “No” for Veteran who do not qualify for per diem.

VA FORM 10-10SH, AUG 2023

82. SIGNATURE OF VA PHYSICIAN/APRN/PA - Enter Signature of VA
Physician, or Advanced Practice Registered Nurse (APRN), or
Physician Assistant (PA).
NOTE: VA clinician signature in block 82 indicates approval of level of care
recommended by SVH physician in block 41. However, if the VA
Clinician do not agree with the SVH Physician level of care
recommendation, then per diem is not approved and denial letter must
be sent to the State Home with Appeal Rights.
83. DATE - Date of VA Physician, or APRN, or PA signature.

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