Care Expense Questions

Someone asked earlier what questions need to be answered in order to have continuing care counted as a medical expense. Listed below is the full text of what is asked.

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?                0 Yes 0 No
If No, when will the care end?
Has the patient applied for Medicaid?     0 Yes 0 No

Is part of the patient’s cost covered by Medicaid, Medicare, or insurance?
0 Yes 0 No
When did coverage begin?

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

Current rate   Rate:$ per month
Effective Date:
Prior Rate (if applicable)   Rate:$ per month
Effective Date:

FOR NURSING HOME CARE ADD:

Is your facility licensed by the State?       0 Yes 0 No
Is your facility Medicaid approved?       0 Yes 0 No
Is the patient in your nursing home because of a physical or mental disability?                     0 Yes 0 No
Do you provide either skilled or intermediate level nursing care to the patient?                     0 Yes 0 No

What was the admitting diagnosis?



FOR IN HOME CARE ADD:

Do you provide any medical or nursing services for the patient? (i.e. administering medication; physical or mental therapy; assisting with personal hygiene, dressing, bathing; etc.)         0 Yes 0 No

Describe the services you provide:


Are you a licensed health professional? (registered nurse, licensed vocational nurse, or licensed practical nurse)                                 0 Yes 0 No

If Yes, provide your license number:

If you charge by the hour, please list your hourly rate and weekly hours worked:

Hourly Rate:   Weekly Hours:

FOR OTHER TYPES OF CARE FACILITIES ADD:

Indicate type of facility: 0 Foster Home 0 Adult Day Care 0 Rest Home
0 Group Home 0 Assisted Living

Do you provide any medical or nursing services for the patient? (i.e. administering medication; physical or mental therapy; assisting with personal hygiene, dressing, bathing; etc.)         0 Yes 0 No

Describe the services you provide:




If the patient receives medical or nursing services, are the services provided or supervised
by a licensed health professional? (registered nurse, licensed vocational nurse, or licensed practical nurse)                               0 Yes 0 No
We must have the monthly charge broken down into the following two categories:

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

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