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,-2026

1. Click ‘Get Form’ to open it in the editor.
2. 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.
3. 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.
4. 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.
5. Finally, both the nursing home official and claimant must sign and date at the end of the form to validate it before submission.

Utilize our platform for free assistance in completing this form efficiently!