care expense statement form care expense statement form care expense statement form c How to Handle Care Expenses: The Care Expense Statement Form Handling the ever-growing cost of long-term or elder care for a loved one can feel daunting and stressful. You may be juggling many different responsibilities while trying to handle mounting bills on top of it all. Thankfully, there are resources available to help make this process a little bit easier. One such resource is the care expense statement form provided by the Elder Law Answers website. This document can help you keep track of all your expenses related to long-term or elder care, so you can stay organized and better manage your finances. In this article, we'll go over exactly what information is included in a
Question | Answer |
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Form Name | Care Expense Statement Form |
Form Length | 2 pages |
Fillable? | No |
Fillable fields | 0 |
Avg. time to fill out | 30 sec |
Other names | va child care letter fillable, care expense statement, irs form 8049, expense statement home |
Care Expense Statement
Section 1: General Information (To be completed by the facility administrator. Please Print.)
VA Claim Number or SSN:
Veterans Name:
Patient’s Name:
Check the box which describes the patient’s care status:
In Home Care
Nursing Home Care
Other Care Facility (Foster Home, Adult Day Care, Rest Home, Group Home, Assisted Living)
Name of facility or care provider: |
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Phone number of facility or care provider: __________________________________ |
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Address of facility or care provider: |
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__________________________________ |
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__________________________________ |
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Date entered facility or in home care began |
__________________________________ |
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Will the patient need this care indefinitely |
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Yes |
No |
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If No, when will the care end? |
_____________________________________________ |
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Total monthly charge for the patient |
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$ |
per month: |
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Has the patient applied for |
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Yes |
No |
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Is part of the patient’s cost covered by Medicaid, Medicare, or insurance |
Yes |
No |
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If Yes, please answer the following: |
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What is the source of payment? |
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______________________ |
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What is the monthly amount covered by this source? |
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$ |
per month: |
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When did coverage begin? |
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______________________ |
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What monthly amount does the veteran or patient pay from |
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his/her own funds which is not reimbursed by one of the sources |
$ |
per month: |
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listed above? |
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(If the patient is receiving Medicaid, what amount does Medicaid take from the patient)
Continue on page 2
Be sure to sign and date
Section 2:
(To be completed by the care provider only if patient is being provided
Do You provide any medical or nursing services for the patient?
Yes
No
(i.e. administering medication, physical or mental therapy, assisting with personal hygiene, dressing bathing; etc.)
Describe the services you provide:_________________________________________________
Are you a licensed health professional? (RN, LVN or LPN) |
Yes |
No |
If Yes, provide your license number: ________________________________________
Section 3: Nursing Home Information
(To be completed by the facility administrator only if the patient is in a nursing home.)
Is your facility licensed by the State?
Is your facility Medicaid
Yes
Yes
No
No
Is the patient in your nursing home because of a physical or mental disability? |
Yes |
No |
Do you provide either skilled or intermediate level nursing care to the patient? |
Yes |
No |
What was the admitting diagnosis? _______________________________________________
Section 4: Other Care Facility Information
( To be completed by the facility administrator only if the patient is in a foster home, adult day care, rest home, group home or assisted living)
Indicate type of facility |
Assisted Living |
Rest Home |
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Adult Day Care |
Group Home |
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Do you provide any medical or nursing services for the patient?
Foster Home
Other _____________
Yes No
(i.e. administering medication, physical or mental therapy, assisting with personal hygiene, dressing bathing; etc.)
Describe the services you provide: ________________________________________________
If the patient receives medical or nursing services, are the services |
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Yes |
No |
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provided or supervised by a licensed health professional (RN, LVN, LPN) |
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We must have the monthly charge broken down into the following categories: |
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1. |
Base Rate (includes room, meals, laundry, housekeeping): $ |
per month: |
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2. |
Medical and Nursing Services: |
$ |
per month: |
Section 5: Signatures (To be completed by the facility administrator/care provider and veteran/widow)
I certify that the above statements are true and correct to the best of my knowledge and belief.
___________________________________________________ |
__________________________________ |
Signature of facility administrator or care provider |
Date |
I certify that the above statements are true and correct to the best of my knowledge and belief. I am paying $_________ per month for my care from my own funds.
___________________________________________________ |
__________________________________ |
Signature of Veteran or Beneficiary |
Date |