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Get VA 10-0114R

643.9301 Phone: 321.397.6594 SUBJECT Request for Community Nursing Home Authorization FROM TELEPHONE NUMBER FTS COMMERCIAL Coordinator The following information is included in the pages of this fax: _____ VA Community Nursing Home Program Release of Information signed by the veteran or the power of attorney or legal representative. Please include documentation of lack of capacity to consent to placement if not signed by the Veteran. _____ PASSR, if this is the first SNF admission _____ 300.

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