Va Form 10 1170 PDF Details

The VA 10 1170 form serves as a crucial document for providers looking to furnish long-term care services to beneficiaries of Veterans Affairs. It is meticulously designed to ensure that veterans receive the highest standard of care by evaluating the qualifications of providers through a systematic application process. The necessity of this form is underscored by its compliance with the Paperwork Reduction Act of 1995, indicating the government's commitment to streamline administrative procedures while maintaining rigorous standards. Each section of the form—from the provider's details to capacity and service schedules—plays a pivotal role in determining eligibility and capability to offer these essential services. Moreover, the inclusion of provider agreements and the requirement for detailed information on the facility's features, like the fire sprinkler system and the professional qualifications of the nursing director, highlight the comprehensive nature of the evaluation process. This meticulous attention to detail ensures that the veterans' welfare is placed at the forefront of long-term care considerations, marking the VA 10 1170 as more than just a form—it's a gateway to providing veterans with the quality care they deserve.

QuestionAnswer
Form NameVa Form 10 1170
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other namesva long burden download, va 1170, application long affairs online, application furnishing care search

Form Preview Example

OMB Number 2900-0616

Estimated Burden: 10 min.

APPLICATION FOR FURNISHING LONG-TERM CARE

SERVICES TO BENEFICIARIES OF VETERANS AFFAIRS

The Paperwork Reduction Act requires us to notify you that this information collection is in accordance with the clearance requirements of section 3507 of the Paperwork Reduction Act of 1995. We may not conduct or sponsor and you are not required to respond to a collection of information unless it displays a valid OMB number. We anticipate that the time expended by all individuals who complete this form will average 10 minutes. This includes the time it will take to read instructions, gather the necessary facts and complete the form. This information is collected under the authority of Title 38, Part II, Sections 1710 and 1730. This information is used to determine your qualifications to provide Long-Term Care. Although this information is voluntary, failure to provide it will delay or prevent our approval of your agency. Comments regarding this burden estimate or any other aspect of this collection, including suggestions for reducing the burden may be sent to VHA Clearance Officer (19E1); Department of Veterans Affairs; 810 Vermont Ave. NW; Washington, DC 20420. DO NOT SEND YOUR APPLICATION TO THIS ADDRESS.

1A. NAME/ADDRESS OF PROVIDER

(Name, City, State, County & Zip)

1B. TELEPHONE NUMBER

2. MEDICARE PROVIDER NO.

3.IF THIS AGENCY IS PART OF A CHAIN, SPECIFY WHICH ONE

4.IS PROVIDER LICENCED OR APPROVED BY STATE IN WHICH LOCATED

YES

NO

5. PROVIDER IS CERTIFIED FOR

6. TOTAL CAPACITY

7. NUMBER OF CLIENTS

8. NAME OF PHYSICIAN WHO ADVISED AGENCY

PARTICIPATION IN MEDICARE/

(Specify number)

ON FILING DATE

 

ON PROFESSIONAL MATTERS

 

MEDICAID PROGRAM

 

 

 

 

 

 

 

 

YES

NO

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

9A. NAME OF DIRECTOR OF NURSING SERVICE

9B. IS DIRECTOR CURRENTLY LICENCED IN

9C. REGISTRATION NO.

STATE WHERE NURSING HOME IS LOCATED

 

 

 

 

 

 

 

 

 

 

 

 

YES

NO

 

 

 

 

 

 

 

 

9D. IS THERE AN IN-SERVICE TRAINING

10A. DATE FACILITY BUILT

 

10B. IS THERE AN AUTOMATIC FIRE

PROGRAM FOR ALL NURSING PERSONNEL

 

SPRINKLER SYSTEM THROUGHOUT THE

(N/A for home health)

 

 

 

 

 

 

FACILITY

 

 

 

 

 

 

 

 

 

 

 

 

YES

NO

 

 

 

 

 

YES

NO

 

 

 

 

11. INITIAL SCHEDULE OF SERVICES (CASE-MIX/LEVEL OF CARE)

 

12. AMOUNT (Price)

(Attach additional sheets as necessary.)

VA FORM

SUPERSEDES VA FORM 10-1170, MAR 2004, WHICH WILL NOT BE USED.

 

NOV 2006 (RS) 10-1170

Page 1 of 2

 

APPLICATION FOR FURNISHING LONG-TERM CARE

SERVICES TO BENEFICIARIES OF VETERANS AFFAIRS, CONTINUED

13. FINAL SCHEDULE OF SERVICES (CASE-MIX/LEVEL OF CARE)

14.AMOUNT (Price)

 

(Attach additional sheets as necessary.)

 

 

 

 

 

 

 

 

 

15A. THE PROVIDER IS REQUESTED TO SIGN THIS DOCUMENT

16. PROVIDER AGREEMENT NUMBER

 

AND RETURN THE NUMBER OF COPIES SPECIFIED BELOW TO

 

 

THE ISSUING OFFICE. PROVIDER AGREES TO FURNISH AND

 

 

DELIVER ALL ITEMS SET FORTH OR OTHERWISE IDENTIFIED

 

 

 

17. EFFECTIVE DATES OF AGREEMENT

 

ABOVE AND ON ANY ADDITIONAL SHEET SUBJECT TO THE

 

TERMS AND CONDITIONS SPECIFIED.

 

 

(Start date/end date)

 

 

 

 

 

15B. NUMBER OF COPIES REQUIRED BY ISSUING OFFICE

 

 

 

 

 

 

 

18A. SIGNATURE OF PROVIDER

19A. SIGNATURE OF VA CENTER DIRECTOR OR DESIGNEE

 

 

 

 

 

18B. NAME AND TITLE OF SIGNER

(Type or Print)

18C. DATE SIGNED

19B. NAME OF VA CENTER DIRECTOR OR DESIGNEE (Type or Print)

19C. DATE SIGNED

20. COMMENTS

VA FORM

SUPERSEDES VA FORM 10-1170, MAR 2004, WHICH WILL NOT BE USED.

 

NOV 2006 (RS) 10-1170

Page 2 of 2

 

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AMOUNT Price, FINAL SCHEDULE OF SERVICES, and AMOUNT Price of va long burden download

3. The next segment should be quite easy, A THE PROVIDER IS REQUESTED TO, B NUMBER OF COPIES REQUIRED BY, PROVIDER AGREEMENT NUMBER, EFFECTIVE DATES OF AGREEMENT, A SIGNATURE OF PROVIDER, A SIGNATURE OF VA CENTER DIRECTOR, B NAME AND TITLE OF SIGNER Type or, C DATE SIGNED B NAME OF VA CENTER, C DATE SIGNED, DESIGNEE Type or Print, and COMMENTS - all of these empty fields needs to be filled out here.

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