Texas Veterans Commission Form PDF Details

The Texas Veterans Commission (TVC) form TVC15b, known as the Assisted Living Statement, serves as a crucial document for veterans and their widows residing in assisted living facilities within Texas. Effective since August 2000, this form is meticulously structured to include comprehensive data, demanding specifics such as the name of the veteran or widow, detailed contact information of the assisted living facility including its license number, and the claimant's personal details. Furthermore, it itemizes the substantial financial aspects involved, requiring a declaration of the recurring gross daily charges for assisted living care alongside the amount already expended by the claimant that wasn't compensated by any external sources. The form emphasizes the necessity for a claimant certification, where the signee verifies the financial burdens undertaken out of pocket, advocating this expense to be acknowledged as a continuing deduction from their countable income. It doesn’t stop at financial declarations; the form also probes into the claimant's health, asking if the patient requires assistance or a specific level of care, alongside their eligibility for Medicare, ultimately cementing its role not just as a financial document, but as a critical piece in ensuring the claimant's well-being and rightful benefits are acknowledged and attended to.

QuestionAnswer
Form NameTexas Veterans Commission Form
Form Length1 pages
Fillable?No
Fillable fields0
Avg. time to fill out15 sec
Other namesfrm_TVC_15_b_As sisted_Living_S tatement texas veterans commission nursing home statement form

Form Preview Example

TEXASVETERANSCOMMISSION

TVC15b

ASSISTEDLIVINGSTATEMENT

EFF. 8/2000

Name of veteran must be provided whether statement is completed for veteranorforwidow.

NameofAssistedLivingFacility

Address

TelephoneNumber

LicenseNumber

RE:

NameofVeteran

Claim#orSSN

NameofClaimant

DateofAdmission

Claimant'sMailingAddress

City State Zip

STATEMENTOFCHARGES

AmountofRecurringGrossDailyChargesforAssistedLivingCare $

Amountpaidandnotreimbursed *$

CLAIMANTCERTIFICATION

*Icertifytheamountasidentifiedaboveisbeingpaidfrompersonalfunds. Theseexpensesarepaidoutofmypocketwithout reimbursementfromanysource. Irequestthisamountbeusedasacontinuingdeductionfrommycountableincome.

 

SignatureofWitness**

 

 

 

SignatureofClaimant

 

 

 

 

 

 

 

**NOTE: Ifclaimantsignswithhis/hermark,themark

 

SignatureofWitness**

 

 

 

mustbewitnessedbytwowitnesses.

 

 

 

 

 

 

 

 

 

STATUSOFCLAIMANT:

 

 

 

 

 

Patientrequiresassistance?

 

 

oraresidence(needsdwelling)?

 

 

 

 

 

 

 

 

 

DisabilitiesRequiringassistance:

 

 

 

 

 

 

LevelofCare

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

ADDITIONALREMARKS:

 

 

 

 

 

IsClaimanteligibleforMedicare?

DateSigned

SignatureofAssistedLiving

 

FacilityAdministratororAgent

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