VA · Official form

VA Form 21-0779: Request for Nursing Home Information in Connection with Claim for Aid and Attendance

VA Form 21-0779 is completed by a nursing home official to verify that a claimant is a patient in the facility, supporting a claim for Aid and Attendance benefits.

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What is VA Form 21-0779?

VA Form 21-0779, Request for Nursing Home Information in Connection with Claim for Aid and Attendance, documents that a veteran or other claimant is a patient in a nursing home. Nursing home status matters for VA pension with Aid and Attendance, because a claimant in a nursing home due to disability can qualify for the higher Aid and Attendance rate.

The form is filled out by an official of the nursing home, not by the claimant. It covers the date of admission, the level of care provided, whether the patient is covered by Medicaid, and the monthly out-of-pocket cost, which affects how VA counts medical expenses in the pension calculation.

Who files VA Form 21-0779?

Nursing home administrators or officials verifying a patient's status for a VA claim
Veterans or surviving spouses in a nursing home claiming pension with Aid and Attendance
Family members coordinating an Aid and Attendance claim for a nursing home resident
Representatives assembling evidence for a pension claim

How to fill out VA Form 21-0779

Enter the claimant's name, file number, and Social Security number in the identification section.
Have a nursing home official complete the facility information, admission date, and level of care sections.
Record Medicaid status and the monthly charges the patient pays out of pocket.
Have the nursing home official sign and date the certification.
Submit the completed form with the pension or Aid and Attendance claim, upload it through va.gov, or mail it to the address in the form instructions.

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Page 1 50 fields

NOTE: You may either complete the form online or by hand. If completing by hand, print neatly and legibly in ink, and completely fill in

1. Veteran's Name. Enter Last Name.

1. Veteran's Name. Enter Middle Initial.

3. V. A. File Number

4. Date of Birth. Enter 2 digit Month.

4. Date of Birth. Enter 2 digit day.

4. Date of Birth. Enter 4 digit year.

8. Claimant's Date of Birth. Enter 2 digit Month.

8. Claimant's Date of Birth. Enter 2 digit day.

8. Claimant's Date of Birth. Enter 4 digit year.

SECTION 2. CLAIMANT'S IDENTIFICATION INFORMATION (Complete this section ONLY IF the claimant is NOT the veteran). 5. Claimant's Name. Enter

5. Claimant's Name. Enter Last Name.

5. Claimant's Name. Enter Middle Initial.

7. Claimant's V. A. File Number (If applicable).

10. Address of Nursing Home. Enter Number and Street.

10. Address of Nursing Home. Enter City.

10. Address of Nursing Home. Enter Apartment or Unit Number.

10. Address of Nursing Home. Enter ZIP or Postal Code. Enter last 4 digits.

10. Address of Nursing Home. Enter ZIP or Postal Code. First 5 digits.

10. Address of Nursing Home. Enter Country.

10. Address of Nursing Home. Enter State or Province.

11. Date Admitted to Nursing Home. Enter 2 digit Month.

11. Date Admitted to Nursing Home. Enter 2 digit day.

11. Date Admitted to Nursing Home. Enter 4 digit year.

14. B. Date Medicaid Plan Began. Enter 2 digit Month.

14. B. Date Medicaid Plan Began. Enter 2 digit day.

14. B. Date Medicaid Plan Began. Enter 4 digit year.

21. Date Signed. Enter 2 digit Month.

21. Date Signed. Enter 2 digit day.

21. Date Signed. Enter 4 digit year.

19. NURSING HOME OFFICIAL'S OFFICE TELEPHONE NUMBER (Include Area Code). Enter Area Code.

19. NURSING HOME OFFICIAL'S OFFICE TELEPHONE NUMBER Enter middle three numbers.

19. NURSING HOME OFFICIAL'S OFFICE TELEPHONE NUMBER Enter last four numbers.

19. Enter International Phone Number (If applicable).

2. Social Security Number. Enter First Three Digits.

2. Social Security Number. Enter middle 2 digits.

2. Social Security Number. Enter Last Four Digits.

6. Claimant's Social Security Number. Enter First Three Digits.

6. Claimant's Social Security Number. Enter middle 2 digits.

6. Claimant's Social Security Number. Enter Last Four Digits.

15. Enter AMOUNT. Last 3 digits.

15. MONTHLY AMOUNT PATIENT IS RESPONSIBLE FOR OUT OF POCKET. Enter AMOUNT. 3 digits.

15. Enter AMOUNT. 2 digit cents.

9. Name of Nursing Home.

17. Nursing Home Official's Name (First and Last).

18. Nursing Home Official's Title.

3. IS THE IN-HOME CARE PROVIDED BY A LICENSED MEDICAL PROFESSIONAL? (A licensed health care provider refers to a person licensed to furnish

12. IS THE NURSING HOME A MEDICAID APPROVED FACILITY? Check box. YES

14. A. IS THE PATIENT COVERED BY MEDICAID? (If "Yes," complete Item 14B). Check box. YES

13. HAS THE PATIENT APPLIED FOR MEDICAID? Check box. YES

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Frequently asked questions

Who fills out VA Form 21-0779?

A responsible official at the nursing home completes and signs it. The claimant or family typically provides the identification details and asks the facility to complete the rest.

Do I also need a doctor's examination form?

Often yes. Claimants for Aid and Attendance who are not in a nursing home generally use VA Form 21-2680, completed by a physician. A nursing home patient uses 21-0779 to verify facility status; VA may still request medical evidence. Check the current instructions at va.gov.

VA Form 21-0779: Request for Nursing Home Information in Connection with Claim for Aid and Attendance

What is VA Form 21-0779?

Who files VA Form 21-0779?

How to fill out VA Form 21-0779

Quick fill VA Form 21-0779 on this page

Frequently asked questions

Related forms

VA Form 21-2680: Examination for Housebound Status or Permanent Need for Regular Aid and Attendance

VA Form 21P-527EZ, Application for Veterans Pension

VA Form 21P-534EZ, Application for DIC, Survivors Pension, and/or Accrued Benefits