What form do I print

[terric]

I am sooooo confused. My mom lives between my brother and myself. We help her dress, bathe and so on. She may soon be going into an assisted living facility, but in the meantime I have been told she does qualify for aid and attendancehile living w/us. Is it the 21-534 Form or another form that has to be filled out and sent in.

[vetadmin]

For the surviving spouse it is 21-534.  Here is a link to step-by-step directions to help.

www.veteranaid.org/apply.php

[VSR]

You will also need an 2680 and have the care provider send in the following information:

Veteran’s name:  _________________________________________________

Patient’s name:  __________________________________________________

Name of facility or care provider:  ___________________________________

Phone number of facility or care provider:  _____________________________

Address of facility or care provider:  __________________________________

               __________________________________

               __________________________________

Date entered facility or in-home care began:  ____________________________

Date patient left facility (if applicable):  ________________________________

Will the patient need this care indefinitely?        Yes____  No____

If No, when will the care end?  ________________________________________

Has the patient applied for Medicaid?        Yes____  No____

Is part of the patient’s cost covered by
Medicaid, Medicare, or insurance?           Yes____  No____

When did coverage begin?  ____________________________________________

What monthly amount does the veteran or patient pay from his/her own funds?

Effective date:  ______________   $__________ per month

   

 
FOR NURSING HOME CARE:

Is your facility licensed by the State?         Yes____  No____

Is your facility Medicaid approved?         Yes____  No____

Is the patient in your nursing home because of
Physical or mental disability?            Yes____  No____

Do you provide either skilled or intermediate
level nursing care to the patient?         Yes____  No____

What was the admitting diagnosis?  ____________________________________

_________________________________________________________________

FOR OTHER TYPES OF CARE FACILITIES:
Indicate type of facility:
   
   ____ Foster Home      ____ Adult Day Care

   ____ Rest Home      ____ Group Home

   ____ Assisted Living

Do you provide any medical or nursing
services for the patient?            Yes____  No____
(i.e. administering medication; physical/mental therapy; assisting with personal hygiene, dressing, bathing, etc.)

Describe the services you provide:  ____________________________________

__________________________________________________________________

If the patient receives medical or nursing services,
are the services provided or supervised by a
licensed health professional?            Yes____  No____
(registered nurse, licensed vocational nurse, or licensed practical nurse)

We must have the monthly charge broken down into the following two categories:

   1.  Base Rate:               $__________ per month
      (includes room, meals, laundry, housekeeping, etc.)

   2.  Medical and Nursing Services:      $__________ per month


SIGNATURES:

I certify that the above statements are true and correct to the best of my knowledge and belief.

_________________________________________________________________
Signature of Facility Administrator or Care Provider         Date


I certify that the above statements are true and correct to the best of my knowledge

and belief.  I am paying $__________ per month for my care from my own funds.

___________________________________________________________________
Signature of Veteran or Beneficiary               Date

[VSR]

By the way, that is the exact text we use in VA letters, so it should save you a step

[vetadmin]

Max,

Thanks for sharing this with everyone.

[VSR]

Yup we used to have a form for that info, but it was something we made on station that was never formally approved by Central Office so it got pulled back.  Now we just insert that text into our letters requesting that information.

[new57]

hey max,

i used that form for my father's app.

it was given to me by a 3rd party company that i ultimately did not use to help with the submission.

isn't there a page 3, that is filled in for home health care use?

is this a form i should scan and make available to Debbie to give out?

e

[pattyclarke]

This is a form that I had in my file that I downloaded from the VA site. Here's link:
http://www4.va.gov/vaforms/search_action.asp?FormNo=21-2680&tkey=&Action=Search
What I downloaded is only a 2 page form.

Patty

[VSR]

hey max,

i used that form for my father's app.

it was given to me by a 3rd party company that i ultimately did not use to help with the submission.

isn't there a page 3, that is filled in for home health care use?

is this a form i should scan and make available to Debbie to give out?

e

The part under "other types of care facilities should cover in-home care.  It doesn't really matter how you format it, as long as VA ends up getting that information. So I'm not sure how much value there would be in turning it into an informal form, but to each his own.

[jpez]

This is a form that I had in my file that I downloaded from the VA site. Here's link:
http://www4.va.gov/vaforms/search_action.asp?FormNo=21-2680&tkey=&Action=Search
What I downloaded is only a 2 page form.

Patty

Pattyclark, that 2 page form is 21-2680, for the doctor to sign not for assisted living expenes or home care expenses