Loading
Form preview picture

Get Va Form 21 0779 Fillable 2020-2024

Whitehouse. gov/omb/library/OMBINV. VA. EPA. html VA. If you desire you can call 1-800-827-1000 to get information on where to send comments or suggestions about this form. VA FORM MAR 2010 21-0779 SUPERSEDES VA FORM 21-0779 MAR 2004 WHICH WILL NOT BE USED. 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 call VA toll-free at 1-800-827-1000. Hearing Impaired TDD line 1-800-829-4833. Section I - IDENTIFICATION INFORMATION 1A. NAME OF NURSING HOME 1B. ADDRESS OF NURSING HOME 2. ADDRESS OF VA REGIONAL OFFICE 3. FIRST NAME - MIDDLE INITIAL- LAST NAME OF CLAIMANT 4. SOCIAL SECURITY NUMBER 5. VA FILE NUMBER SECTION II - NURSING HOME INFORMATION To be completed by a Nursing Home Official 6. DATE ADMITTED TO NURSING HOME Month Day Year 7. DATE MEDICAID BEGAN Month Day Year 8. AMOUNT PATIENT IS RESPONSIBLE FOR OUT OF POCKET 9. I CERTIFY THAT THE CLAIMANT IS A PATIENT IN THIS FACILITY BECAUSE OF MENTAL OR PHYSICAL DISABILITY AND IS RECEIVING Check one SKILLED NURSING CARE INTERMEDIATE NURSING CARE 10. NURSING HOME OFFICIAL S NAME First Last Please print TELEPHONE NUMBER Include Area Code 13A. SIGNATURE OF NURSING HOME OFFICIAL 13B. DATE SIGNED PRIVACY ACT NOTICE The VA will not disclose information collected on this form to any source other than what has been authorized under the Privacy Act of 1974 or Title 5 Code of Federal Regulations 1. 526 for routine uses i*e* civil or criminal law enforcement congressional communications epidemiological or research studies the collection of money owed to the United States litigation in which the United States is a party or has an interest the administration of VA programs and delivery of VA benefits verification of identity and status and personnel administration as identified in the VA system of records 58VA21/22/28 Compensation Pension Education and Vocational Rehabilitation and Employment Records - VA published in the Federal Register. While you are not required to respond your cooperation in providing this relevant and necessary information will help us determine the claimant s maximum benefit entitlement under the law. Information that you furnish may be utilized in computer matching programs with other Federal or state agencies for the purpose of determining the claimant s eligibility to receive VA benefits as well as to collect any amount owed to the United States by virtue of the claimant s participation in any benefit program administered by the Department of Veterans Affairs. 1115 1 E 38 U*S*C. 1311 c 38 U*S*C. 1315 h. Title 38 United States Code allows us to ask for this information* We estimate that you will need an average of 10 minutes to review the instructions find the information and complete this form* VA cannot conduct or sponsor a collection of information unless a valid OMB control number is displayed* You are not required to respond to a collection of information if this number is not displayed* Valid OMB control numbers can be located on the OMB Internet Page at www.

How It Works

va form 21 0779 printable rating
4.8Satisfied
50 votes

Tips on how to fill out, edit and sign Veterans administration form 21 0779 online

How to fill out and sign 21 0779 pdf online?

Get your online template and fill it in using progressive features. Enjoy smart fillable fields and interactivity. Follow the simple instructions below:

The days of terrifying complicated legal and tax documents are over. With US Legal Forms the whole process of creating official documents is anxiety-free. A powerhouse editor is directly at your fingertips supplying you with multiple beneficial tools for filling out a VA 21-0779. The following tips, along with the editor will assist you with the entire process.

  1. Hit the Get Form button to start enhancing.
  2. Switch on the Wizard mode on the top toolbar to have more pieces of advice.
  3. Complete each fillable area.
  4. Be sure the info you fill in VA 21-0779 is updated and correct.
  5. Indicate the date to the record using the Date option.
  6. Click on the Sign button and create an e-signature. You will find three available alternatives; typing, drawing, or capturing one.
  7. Make sure that each field has been filled in properly.
  8. Click Done in the top right corne to export the record. There are various alternatives for getting the doc. An attachment in an email or through the mail as a hard copy, as an instant download.

We make completing any VA 21-0779 easier. Use it now!

Get form

Experience a faster way to fill out and sign forms on the web. Access the most extensive library of templates available.

Video instructions and help with filling out and completing form 21 0779

Take full advantage of our instructional video tutorial for filling out and delivering Form with our online editor. Get started now so you can relax afterwards.

Get This Form Now!

Use professional pre-built templates to fill in and sign documents online faster. Get access to thousands of forms.

Keywords relevant to 2010 veterans 21 0779

  • 210779
  • 2010 21 va
  • va 779
  • va 21 0779 instructions
  • 21 0779 va
  • 21 0779
  • 21 0779 form pdf
  • 0779 form
  • 0779
  • va form 0779
  • veterans affairs 21 0779
  • veterans 21 0779
  • va 210779
  • vba 21 0779
  • va aid and attendance form 21 0779
If you believe that this page should be taken down, please follow our DMCA take down processhere.
Ensure the security of your data and transactions

USLegal fulfills industry-leading security and compliance standards.

  • 
                            VeriSign logo picture

    VeriSign secured

    #1 Internet-trusted security seal. Ensures that a website is free of malware attacks.

  • Accredited Business

    Guarantees that a business meets BBB accreditation standards in the US and Canada.

  • 
                            TopTenReviews logo picture

    TopTen Reviews

    Highest customer reviews on one of the most highly-trusted product review platforms.