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Get VA 10-1170 2006-2024

AMOUNT Price Attach additional sheets as necessary. VA FORM NOV 2006 RS 10-1170 SUPERSEDES VA FORM 10-1170 MAR 2004 WHICH WILL NOT BE USED. OMB Number 2900-0616 Estimated Burden 10 min* APPLICATION FOR FURNISHING LONG-TERM CARE SERVICES TO BENEFICIARIES OF VETERANS AFFAIRS The Paperwork Reduction Act 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 all individuals who complete this form will average 10 minutes. This includes the time it will take to read instructions gather the necessary facts and complete the form* This information is collected under the authority of Title 38 Part II Sections 1710 and 1730. This information is used to determine your qualifications to provide Long-Term Care. Although this information is voluntary failure to provide it will delay or prevent our approval of your agency. Comments regarding this burden estimate or any other aspect of this collection including suggestions for reducing the burden may be sent to VHA Clearance Officer 19E1 Department of Veterans Affairs 810 Vermont Ave. NW Washington DC 20420. DO NOT SEND YOUR APPLICATION TO THIS ADDRESS* 1A. NAME/ADDRESS OF PROVIDER 1B. TELEPHONE NUMBER 3. IF THIS AGENCY IS PART OF 4. IS PROVIDER LICENCED A CHAIN SPECIFY WHICH ONE OR APPROVED BY STATE Name City State County Zip IN WHICH LOCATED 2. MEDICARE PROVIDER NO. YES 5. PROVIDER IS CERTIFIED FOR PARTICIPATION IN MEDICARE/ MEDICAID PROGRAM 6. TOTAL CAPACITY 7. NUMBER OF CLIENTS Specify number ON FILING DATE NO 8. NAME OF PHYSICIAN WHO ADVISED AGENCY ON PROFESSIONAL MATTERS 9A. NAME OF DIRECTOR OF NURSING SERVICE 9B. IS DIRECTOR CURRENTLY LICENCED IN STATE WHERE NURSING HOME IS LOCATED 9D. IS THERE AN IN-SERVICE TRAINING PROGRAM FOR ALL NURSING PERSONNEL 10A. DATE FACILITY BUILT N/A for home health 11. INITIAL SCHEDULE OF SERVICES Case-mix/level of care 9C. REGISTRATION NO. 10B. IS THERE AN AUTOMATIC FIRE SPRINKLER SYSTEM THROUGHOUT THE FACILITY 12. Page 1 of 2 13. FINAL SCHEDULE OF SERVICES Case-mix/level of care 15A. THE PROVIDER IS REQUESTED TO SIGN THIS DOCUMENT 16. PROVIDER AGREEMENT NUMBER AND RETURN THE NUMBER OF COPIES SPECIFIED BELOW TO THE ISSUING OFFICE* PROVIDER AGREES TO FURNISH AND DELIVER ALL ITEMS SET FORTH OR OTHERWISE IDENTIFIED ABOVE AND ON ANY ADDITIONAL SHEET SUBJECT TO THE 17. EFFECTIVE DATES OF AGREEMENT Start date/end date TERMS AND CONDITIONS SPECIFIED. 15B. NUMBER OF COPIES REQUIRED BY ISSUING OFFICE 18A. SIGNATURE OF PROVIDER 18B. NAME AND TITLE OF SIGNER Type or Print 18C. DATE SIGNED 19B. NAME OF VA CENTER DIRECTOR OR DESIGNEE Type or Print 20. OMB Number 2900-0616 Estimated Burden 10 min* APPLICATION FOR FURNISHING LONG-TERM CARE SERVICES TO BENEFICIARIES OF VETERANS AFFAIRS The Paperwork Reduction Act 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. .

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