Request for Nursing Home Information in Connection with Claim for Aid and Attendance
This form is used to gather information from nursing homes or assisted living facilities about a veteran's care needs in support of Aid and Attendance claims.
Used in these claim stages:
Last updated by VA: January 1, 2024
How to Complete This Form
This form is completed by the nursing home or care facility:
**Section I - Veteran Information**
Basic identifying information.
**Section II - Facility Information**
Name, address, and contact information for the facility.
**Section III - Level of Care**
Facility documents:
- Type of care provided (skilled nursing, assisted living, etc.)
- Date of admission
- Whether veteran is bedridden
- Level of assistance needed with daily activities
- Supervision requirements
**Section IV - Cost of Care**
Monthly cost of care and what services are included.
**Section V - Certification**
Facility representative signs.
Helpful Tips
- The facility's social worker can usually help complete this form
- Make sure the level of care documented matches your actual needs
- This form helps establish need for Aid and Attendance benefits
- The cost information may be relevant for VA pension claims too
- Keep copies of all care agreements and billing statements
Common Mistakes to Avoid
- Not providing complete information about care needs
- Facility understating the level of care provided
- Not including all services in the cost breakdown
Deadline Information
Submit when claiming Aid and Attendance while in a nursing home or assisted living facility.