Download VA Form 21-0779 Request for Nursing Home Information in Connection With Claim for Aid and Attendance
VA Form 21-0779 Instructions
The VA form 21-0779 is distributed without the filling guidelines provided.
How to Fill out VA Form 21-0779?
The form consists of four sections:
- Section I. Veteran/Claimant's Identification information. If you are a veteran or a claimant, enter your full name, social security number, VA file number, date of birth, and service number, if applicable.
- Section II. Nursing Home Information. Provide the name and address of the nursing home, including the unit number and street or rural route, P.O. box, city, state, zip code, and country.
- Section III. General Information. It is completed by a nursing home official. State the date of the patient's admission to the nursing home, the date Medicaid or equivalent plan began, monthly amount patient is responsible for out of pocket. Provide your full name, title, and telephone number. Answer several questions by providing data, whether the nursing home facility is Medicaid or equivalent has been approved, whether the patient has applied for Medicaid or an equivalent plan. You have to certify that the patient is in the facility because of mental or physical disability and is receiving skilled nursing care or intermediate nursing care.
- Section IV. Declaration of Intent. Lastly, certify that the statements on this form are true and correct to the best of your knowledge and belief, sign and date the form.
The VA might require the following papers after the submission of the VA Form 21-0779. Provide them as soon as possible:
- DD Form 214, Certificate of Release or Discharge from Active Duty;
- VA Form 21-22, Appointment of Veterans Service Organization (VSO) as Claimant's Representative, if a VSO is acting as the claimant's representative. A VSO is a professional veteran affairs advocate;
- VA Form 21-22A, Appointment of Individual as Claimant's Representative, if an individual is acting as the claimant's representative;
- VA Form 21-4142, Authorization to Release Information to VA;
- VA Form 21-2680, Examination for Housebound Status or Permanent Need for Regular Aid and Attend;
- VA Form 21P-8416, Medical Expense Report.
In addition to the forms, the claimant should gather the following documents:
- Marriage Certificate and Death Certificate;
- Asset Information;
- Verification of Income;
- Proof of Medical Premiums;
- Voided Check for Aid and Attendance Direct Deposit.
The claimant filing this form should remember that this form can be used for both supporting a claim for a higher level of pension and the need for certain medical expenses. Those two purposes should be kept in mind when a claimant opts for a VA claim, and when reviewing its completion by the nursing home to make sure there are no unexpected results with the claim.
Where to Mail VA Form 21-0779?
The completed VA Form 21-0779 is filed as part of a fully developed claim. The form, completed either manually or online, should be presented in person or mailed to the local VA regional office.
A duly appointed service organization, an employee of the local regional VA office, or a VA approved accredited agent or attorney can help a veteran or surviving spouse file a claim. The claimant may contact a Veterans Service Officer from a local Veterans Service Organization.
The Fully Developed Claim (FDC) program is the fastest way to get the claim processed. It requires submitting all evidence or supporting papers when filing the claim. When filing the standard claim, the claimant only gives the VA permission to gather evidence. The claimant should complete and submit the VA Form 21P-527EZ, Application for Pension and all supporting documents to the VA.
The VA Form 21-0779 is necessary when the claimant is in the nursing home. Participating in the FDC program is optional and does not affect the claimant's benefits. If the claim is filed under the FDC and the VA requires additional information, it will remove the claim from the program and process it in a standard way.