Get Va 21-0779 2020-2025

The VA 21-0779 is a vital form used to request nursing home information in connection with a claim for aid and attendance. Completing this form accurately is essential for determining eligibility for benefits. This guide will provide you with clear, step-by-step instructions on how to fill out the VA 21-0779 online.

Follow the steps to fill out the VA 21-0779 online effectively.

1. Click ‘Get Form’ button to obtain the VA 21-0779 form and open it in the editor.
2. In Section I, provide the veteran's identification information. Fill in the veteran's full name, Social Security number, date of birth in MM/DD/YYYY format, and the VA file number.
3. If you are filling out the form as a claimant (not the veteran), complete Section II. Enter the claimant's full name, Social Security number, date of birth, and VA file number if applicable.
4. In Section III, provide the nursing home information. Enter the full name of the nursing home and its complete address, including number and street, apartment or unit number, city, state, ZIP code, and country.
5. For Section IV, which must be completed by a nursing home official, include the date the patient was admitted to the nursing home, confirm if it is a Medicaid approved facility, and indicate if the patient has applied for Medicaid or is covered by it. Fill in the monthly amount the patient is responsible for out of pocket and the start date of the Medicaid plan if applicable. The nursing home official must also certify the patient’s status and provide their name, title, and contact number.
6. In Section V, the nursing home official must sign and date the certification to confirm that all statements on the form are true and correct.
7. After reviewing all the information for accuracy, save the changes to your form. You may also choose to download, print, or share the completed VA 21-0779 form as required.

Complete your VA 21-0779 online today to ensure a smooth application process.