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,
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Begin by filling out Section I - IDENTIFICATION INFORMATION. Enter the name and address of the nursing home, along with the claimant's first name, middle initial, last name, VA file number, and social security number.
Proceed to Section II - NURSING HOME INFORMATION. This section must be completed by a nursing home official. Include details such as the date Medicaid began, date admitted to the nursing home, and the amount the patient is responsible for out of pocket.
Ensure that the nursing home official certifies that the claimant is a patient due to mental or physical disability by checking the appropriate box and providing their title and contact information.
Finally, both the nursing home official and claimant must sign and date at the end of the form to validate it before submission.
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Fill out 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, online It's free
You may apply for Aid and Attendance or Housebound benefits by filling out, or have your doctor complete, VA Form 21-2680 (Examination for Housebound Status or Permanent Need for Regular Aid and Attendance) and mailing it to the Pension Management Center (PMC).
What VA forms are needed for aid and attendance?
Use VA Form 21-2680 to apply for Aid and Attendance benefits that will be added to your monthly compensation or pension benefits.
What is VA form 21 0789?
Veterans who are seeking disability benefits from the Department of Veterans Affairs (VA) may need to fill out va form 21 0789. Individuals who believe they have a service-connected disability and are eligible for disability compensation or pension may need to complete this form as part of the application process.
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VA Form 21-0779 - Veterans Benefits Administration
RESPONDENT BURDEN: VA needs this information to determine eligibility for pension and aid and attendance benefits based on nursing home status. Title 38,.
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