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Get VA 21-0779 2020-2024

Whitehouse. gov/omb/library/OMBINV. VA. EPA. html VA. 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 MAR 2010 21-0779 SUPERSEDES VA FORM 21-0779 MAR 2004 WHICH WILL NOT BE USED. OMB Approved No 2900-0652 RESPONDENT BURDEN 10 Minutes REQUEST FOR NURSING HOME INFORMATION IN CONNECTION WITH CLAIM FOR AID AND ATTENDANCE VA DATE STAMP Do Not Write In This Space INSTRUCTIONS For free help in completing this form call VA toll-free at 1-800-827-1000. Hearing Impaired TDD line 1-800-829-4833. Section I - IDENTIFICATION INFORMATION 1A. NAME OF NURSING HOME 1B. ADDRESS OF NURSING HOME 2. ADDRESS OF VA REGIONAL OFFICE 3. FIRST NAME - MIDDLE INITIAL- LAST NAME OF CLAIMANT 4. SOCIAL SECURITY NUMBER 5. VA FILE NUMBER SECTION II - NURSING HOME INFORMATION To be completed by a Nursing Home Official 6. DATE ADMITTED TO NURSING HOME Month Day Year 7. DATE MEDICAID BEGAN Month Day Year 8. AMOUNT PATIENT IS RESPONSIBLE FOR OUT OF POCKET 9. 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 10. NURSING HOME OFFICIAL S NAME First Last Please print TELEPHONE NUMBER Include Area Code 13A. SIGNATURE OF NURSING HOME OFFICIAL 13B. DATE SIGNED 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. 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.

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