ALF 2040.doc-2025

1. Click ‘Get Form’ to open ALF 2040.doc in the editor.
2. Begin by entering the veteran's Last Name, First Name, MI, and SS# in the designated fields.
3. Fill in the Date of Admission and VA File No. in their respective sections.
4. Select the appropriate Level of Care by circling one of the options: Level 1, Level 2, or Level 3.
5. Provide a detailed explanation of the level of care required, including any medical needs and activities of daily living (ADLs).
6. Enter the Basic charges for room and board and any Other charges for medical care, specifying whether these are per day or per month.
7. Indicate if the Veteran is considered a patient or a resident by circling the appropriate option.
8. Provide an explanation for other medical charges if applicable.
9. Complete the facility information section with name, address, city, state, zip code, and telephone number.
10. Have the administrator print their name and provide their signature along with the date at the bottom of the form.

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