VA Form 21-0779 at a glance
What it is: VA Form 21-0779 is the Request for Nursing Home Information in Connection with Claim for Aid and Attendance.
Who signs: The Signature of the Nursing Home Official is REQUIRED.
The Signature of the Nursing Home Official is REQUIRED.
VA uses this form to determine eligibility for pension and aid and attendance benefits based on nursing home status.
A filled-in VA Form 21-0779 example: a nursing home official fills out the request
How to fill out VA Form 21-0779, box by box
Section I - Veteran's identification information
In Section I, enter the Veteran's Name (First, Middle Initial, Last), the Social Security Number, the VA File Number and the Date of Birth (MM/DD/YYYY).
Section II - Claimant's identification information
Complete Section II ONLY IF the claimant is NOT the veteran: enter the Claimant's Name (First, Middle Initial, Last), the Social Security Number, the VA File Number (If applicable) and the Date of Birth (MM/DD/YYYY).
Section III - Nursing home information
In Section III, enter the Name of Nursing Home and its Address (Number and street or rural route, P.O. Box, City, State, ZIP Code and Country).
Section IV - General information
A Nursing Home Official completes Section IV.
Enter the Date Admitted to Nursing Home (MM/DD/YYYY) in Box 11. In Box 12, mark YES or NO: IS THE NURSING HOME A MEDICAID APPROVED FACILITY?
In Box 13, mark YES or NO: HAS THE PATIENT APPLIED FOR MEDICAID? In Box 14A, mark YES or NO: IS THE PATIENT COVERED BY MEDICAID? If "YES," complete Item 14B, the Date Medicaid Plan Began (MM/DD/YYYY). Your state's Medicaid program may use a different name.
In Box 15, enter the Monthly Amount Patient Is Responsible For Out Of Pocket.
In Box 16, certify that the claimant is a patient in this facility because of mental or physical disability and is receiving Skilled Nursing Care or Intermediate Nursing Care (Check one).
Enter the Nursing Home Official's Name (First and Last) in Box 17, the Nursing Home Official's Title in Box 18 and the Office Telephone Number (Include Area Code) in Box 19, with an International Phone Number (If applicable).
Section V - Certification and signature
In Section V, the Nursing Home Official certifies that the statements on this form are true and correct to the best of my knowledge and belief, enters the Signature (REQUIRED) in Box 20 and enters the Date Signed (MM/DD/YYYY) in Box 21.
More rules for VA Form 21-0779
You may complete the form online or by hand. If completing by hand, print neatly and legibly in ink, and completely fill in each applicable checkbox to help expedite processing of the form.
Common questions about VA Form 21-0779
Where do I file it?
After completing the form, mail it to: Department of Veterans Affairs, Evidence Intake Center, P.O. Box 4444, Janesville, WI, 53547- 4444.
Is there a penalty?
The law provides severe penalties (including fine and/or imprisonment) for willfully submitting any statement or evidence of a material fact you know to be false, or for fraudulent receipt of any document you are not entitled to.
Sources
[1] VA Form 21-0779 (SEP 2023), Request for Nursing Home Information in Connection with Claim for Aid and Attendance, Department of Veterans Affairs (the Official source link on this page).
