What form do I print

Discussion in 'Share Your Personal Experience' started by terric, Apr 6, 2010.

  1. terric

    terric Newbie

    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.
  2. vetadmin

    vetadmin Administrator Staff Member

  3. Max

    Max Hero Member

    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


    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? ____________________________________


    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


    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
  4. Max

    Max Hero Member

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

    vetadmin Administrator Staff Member


    Thanks for sharing this with everyone.
  6. Max

    Max Hero Member

    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.
  7. new57

    new57 Newbie

    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?

  8. pattyclarke

    pattyclarke Newbie

    This is a form that I had in my file that I downloaded from the VA site. Here's link:
    What I downloaded is only a 2 page form.

  9. Max

    Max Hero Member

    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. :)
  10. jpez

    jpez Full Member

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

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