Va Form 10 1170 PDF Details

If you or a loved one have recently been called to serve in the United States Armed Forces, it is important that you understand your rights and responsibilities under both civil and military law. In addition to filing paperwork at a local recruiting office, you must complete the VA Form 10-1170, also known as an Authorization for Disclosure of Information from Department of Veterans Affairs Records/Department of Defense Medical Records. This form grants permission for qualified agencies within the Department of Veteran's Affairs (VA) and Department of Defense (DoD) to release information about your medical history during active military service in order to process any related claims for compensation or benefits. In this blog post we will provide comprehensive instructions on how to fill out VA Form 10-1170 so you can start preparing necessary documentation early on in the process.

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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2. Once your current task is complete, take the next step – fill out all of these fields - FINAL SCHEDULE OF SERVICES, and AMOUNT Price with their corresponding information. Make sure to double check that everything has been entered correctly before continuing!

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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