1170 form-2025

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4.9 out of 5

32 votes

The document is an application form for furnishing long-term care services to beneficiaries of Veterans Affairs, requiring information about the provider's qualifications, licensing, and capacity. It outlines the estimated time to complete the form, legal requirements under the Paperwork Reduction Act, and includes sections for provider details, service schedules, and agreements.

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Click ‘Get Form’ to open the 1170 form in the editor.
Begin by filling out Section 1A with the name and address of your agency. Ensure all details are accurate, including city, state, and zip code.
In Section 1B, enter your telephone number for contact purposes.
Proceed to Section 2 and input your Medicare provider number if applicable.
Complete Sections 3 and 4 by indicating if your agency is part of a chain and whether it is licensed or approved by the state.
Fill out Sections 5 through 10A regarding certification status, total capacity, client numbers, and facility details.
For Sections 11 through 20, provide information on services offered, agreement terms, signatures, and any additional comments as needed.

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2006	4.9 Satisfied (32 Votes)

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What is VA form 21 0958?

In order for us to begin processing your NOD, you must complete, sign, and return VA Form 21-0958, Notice of Disagreement, within one year of the date of the decision notice we sent you on the decision(s) you are intending to appeal, or within 60 days from the date of this notice, whichever is later.

What is form 21 4142?

Use VA Form 21-4142 to give us permission to obtain your personal information from a non-VA source like a private doctor or hospital. Examples of personal information may include your medical treatment, hospitalizations, psychotherapy, or outpatient care.