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.
For the surviving spouse it is 21-534. Here is a link to step-by-step directions to help. www.veteranaid.org/apply.php
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
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.
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
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
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.
Pattyclark, that 2 page form is 21-2680, for the doctor to sign not for assisted living expenes or home care expenses
