Get CA Supportforhome Care Expense Statement

Care Expense Statement Section 1 General Information To be completed by the facility administrator. Please Print. VA Claim Number or SSN Veterans Name Patient s Name Check the box which describes the patient s care status In Home Care Nursing Home Care Other Care Facility Foster Home Adult Day Care Rest Home Group Home Assisted Living Name of facility or care provider Phone number of facility or care provider Address of facility or care provider Date entered facility or in home care began Will the patient need this care indefinitely If No when will the care end Yes No Total monthly charge for the patient Has the patient applied for Medi-Cal Medicaid per month Is part of the patient s cost covered by Medicaid Medicare or insurance If Yes please answer the following What is the source of payment What is the monthly amount covered by this source When did coverage begin What monthly amount does the veteran or patient pay from his/her own funds which is not reimbursed by one of the sources listed above If the patient is receiving Medicaid what amount does Medicaid take from the patient Continue on page 2 Be sure to sign and date Section 2 In-Home Care Information To be completed by the care provider only if patient is being provided In-Home Care Do You provide any medical or nursing services for the patient i.e. administering medication physical or mental therapy assisting with personal hygiene dressing bathing etc. Describe the services you provide Are you a licensed health professional RN LVN or LPN If Yes provide your license number Section 3 Nursing Home Information Is your facility licensed by the State Is the patient in your nursing home because of a physical or mental disability Do you provide either skilled or intermediate level nursing care to the patient What was the admitting diagnosis Section 4 Other Care Facility Information group home or assisted living Indicate type of facility Assisted Living Adult Day Care Rest Home Group Home Foster Home Other provided or supervised by a licensed health professional RN LVN LPN We must have the monthly charge broken down into the following categories 1. Base Rate includes room meals laundry housekeeping 2. Medical and Nursing Services Section 5 Signatures To be completed by the facility administrator/care provider and veteran/widow I certify that the above statements are true and correct to the best of my knowledge and belief. Signature of facility administrator or care provider Date per month for my care from my own funds. Care Expense Statement Section 1 General Information To be completed by the facility administrator. Please Print* VA Claim Number or SSN Veterans Name Patient s Name Check the box which describes the patient s care status In Home Care Nursing Home Care Other Care Facility Foster Home Adult Day Care Rest Home Group Home Assisted Living Name of facility or care provider Phone number of facility or care provider Address of facility or care provider Date entered facility or in home care began Will the patient need this care indefinitely If No when will the care end Yes No Total monthly charge for the patient Has the patient applied for Medi-Cal Medicaid per month Is part of the patient s cost covered by Medicaid Medicare or insurance If Yes please answer the following What is the source of payment What is the monthly amount covered by this source When did coverage begin What monthly amount does the veteran or patient pay from his/her own funds which is not reimbursed by one of the sources listed above If the patient is receiving Medicaid what amount does Medicaid take from the patient Continue on page 2 Be sure to sign and date Section 2 In-Home Care Information To be completed by the care provider only if patient is being provided In-Home Care Do You provide any medical or nursing services for the patient i*e* administering medication physical or mental therapy assisting with personal hygiene dressing bathing etc* Describe the services you provide Are you a licensed health professional RN LVN or LPN If Yes provide your license number Section 3 Nursing Home Information Is your facility licensed by the State Is the patient in your nursing home because of a physical or mental disability Do you provide either skilled or intermediate level nursing care to the patient What was the admitting diagnosis Section 4 Other Care Facility Information group home or assisted living Indicate type of facility Assisted Living Adult Day Care Rest Home Group Home Foster Home Other provided or supervised by a licensed health professional RN LVN LPN We must have the monthly charge broken down into the following categories 1. .