VA Form 21-0779 verifies nursing home care for a claim involving Aid and Attendance. The nursing home official supplies the care information and signs the certification. A family member can help assemble the paperwork, but their signature does not replace the official's required signature.

The current edition is September 2023. I checked the official form page and both pages of the PDF. Its main fields separate four facts that are easy to confuse: admission to the facility, the facility's Medicaid approval, the patient's Medicaid coverage and the amount the patient personally owes each month.

Who needs this form, and what does it establish?

The form's full name is Request for Nursing Home Information in Connection with Claim for Aid and Attendance. VA says it uses the information to determine pension and Aid and Attendance eligibility based on nursing home status.

VA's pension Aid and Attendance guidance says that being a nursing home patient because of disability-related loss of mental or physical abilities is one qualifying circumstance for the additional benefit. Other requirements for the underlying pension still apply. Nursing home residence does not establish every part of pension eligibility.

That page also says a nursing home applicant needs Form 21-0779 in addition to the Aid and Attendance application process. Form 21-2680 collects examination information, and a medical examiner completes its examination section. Form 21-0779 collects the facility's facts.

This distinction helps when a family is gathering paperwork from several people. The claimant or helper provides identifying information, the nursing home verifies its records, and the medical examiner supplies any required examination findings. A person signing one role does not automatically have authority to sign another.

Fictional example: admission before Medicaid coverage

This is a fictional worksheet, not a real patient or facility record. A veteran is admitted to a nursing home on August 3, 2026 because of a physical disability. The facility is Medicaid approved. The patient applied for Medicaid, coverage began September 1, 2026, and the facility's records show a current patient responsibility of $425 per month.

The official will identify the actual care level and sign the completed form. No facility name, medical diagnosis or identifying number is invented for you to copy. The example's dates and amount illustrate different fields, not an eligibility or payment calculation.

Section I: veteran information, Items 1 through 4

On the September 2023 PDF:

  • Item 1: Enter the veteran's first name, middle initial and last name.
  • Item 2: Enter the veteran's Social Security number.
  • Item 3: Enter the VA file number.
  • Item 4: Enter the veteran's date of birth using month/day/year.

The veteran belongs here even if the nursing home patient is a surviving spouse claiming benefits based on that veteran's service. These fields connect the evidence to the relevant VA record.

If you are helping a relative, verify the identifying information from their records. Similar names and an incorrect birth date can make the form harder to associate with the right claim. Keep the completed form private; a sample shared for general feedback should never include actual Social Security or VA file numbers.

Section II: a different claimant, Items 5 through 8

Complete this section only when the claimant is not the veteran.

  • Item 5: Claimant's name.
  • Item 6: Claimant's Social Security number.
  • Item 7: Claimant's VA file number, if applicable.
  • Item 8: Claimant's date of birth.

The fictional veteran is also the patient and claimant, so Section II is unused. If the patient were a surviving spouse seeking their own pension benefit, that person's information would go here.

Do not enter an adult child's information merely because the child is helping collect records. This section identifies the claimant, not the most available family contact or the person paying for postage.

Section III: identify the nursing home, Items 9 and 10

Item 9 asks for the nursing home's name. Item 10 asks for its full address, including unit, city, state, country and postal code where applicable.

Use the actual facility providing the care described in the certification. A corporate billing office, an earlier rehabilitation facility and the current nursing home may have different addresses. Ask the official to verify which facility name and address belong on the form.

These fields also establish which institution the signing official represents. They should agree with the admission and care records used for the remaining answers.

Section IV: the nursing home official completes Items 11 through 19

The heading explicitly assigns this section to a nursing home official. A family member's best estimate should not be presented as the facility's certified answer.

Item 11: date admitted

Enter the nursing home admission date. In the fictional example, this is 08/03/2026. It is not the date Medicaid started or the date someone first asked about VA benefits.

If there have been transfers or separate admissions, ask the official to check the facility's record rather than compressing several stays into one unsupported date.

Item 12: is the facility Medicaid approved?

The official answers Yes or No about the facility. In the fictional example, the answer is Yes.

That answer does not mean every patient has Medicaid coverage. It also does not ask whether the facility participates in Medicare. The form notes that a state's Medicaid program may operate under another name, so match the program to the question.

Item 13: has the patient applied for Medicaid?

This is a separate Yes or No about an application. The fictional answer is Yes. Applying and receiving coverage are different events, which is why the next item exists.

If an application is still pending, the official should answer from the known status. Do not turn an expected approval into current coverage just to make the form look complete.

Items 14A and 14B: coverage and its start date

14A asks whether the patient is covered by Medicaid. If Yes, 14B asks when the Medicaid plan began.

The fictional entries are Yes and 09/01/2026. The admission date remains August 3. Those dates can legitimately differ, and repeating one date in both places would erase useful information.

Item 15: the patient's monthly out-of-pocket responsibility

Enter the monthly amount the patient is responsible for out of pocket. The fictional entry is $425.

This is not automatically the facility's full private-pay charge, the amount Medicaid pays or the amount a relative recently advanced. The official should use the patient's actual responsibility reflected in the relevant facility records. If a balance or recent change makes that amount unclear, resolve the question before certifying it.

The form does not calculate a VA award from this number. It supplies a fact VA can consider with the rest of the claim.

Item 16: certify the reason for care and care level

The official certifies that the claimant is a patient because of mental or physical disability and selects skilled nursing care or intermediate nursing care.

This is not a family preference about which description sounds stronger. The official must select the care actually provided. In the fictional example, the official consults the care record and chooses the matching category.

An assisted-living residence should not simply be relabeled a nursing home to fit the form. If the setting or care category does not match, ask VA or an accredited representative which evidence is appropriate for the actual situation.

Items 17 through 19: identify the official

Item 17 is the official's name. Item 18 is the official's title. Item 19 is the office telephone number, including the area code or applicable international number.

These details let VA identify the person certifying the information and follow up. A patient's family telephone number does not answer the question asking for the official's office number.

Section V: the official signs Items 20 and 21

Item 20 is the nursing home official's required signature. Item 21 is the signing date. The certification says the statements are true and correct to the best of the signer's knowledge and belief.

Before the official signs, compare the admission date, Medicaid dates, patient responsibility and care category with the underlying records. Make sure the signer is certifying the final version. A typed name in Item 17 alone does not satisfy the separate signature field.

Page 2 contains privacy and information-collection notices rather than another set of applicant questions. It does not contain a substitute claimant signature line.

Where to submit, including the two mailing instructions

The VA form page offers an online route and directs users with a completed PDF to submit it through the page. Use that official entry point and follow the instructions for the signed facility information.

For paper submissions, keep these sources distinct:

  • The standalone September 2023 21-0779 PDF prints: Department of Veterans Affairs, Evidence Intake Center, PO Box 4444, Janesville, WI 53547-4444.
  • VA's pension Aid and Attendance application page directs its mailed application to: Department of Veterans Affairs, Pension Intake Center, PO Box 5365, Janesville, WI 53547-5365. That page says to include 21-0779 when the applicant is in a nursing home.

For an Aid and Attendance pension application package, follow that package's instructions. If you are responding to an existing VA request for nursing home information, check its return instructions. If the request and form appear inconsistent, call 800-827-1000, TTY 711, to confirm the destination. Keep the acknowledgment with the submitted copy.

VA's Aid and Attendance page also allows in-person submission at a regional office. I did not verify a current form-specific fax number for 21-0779 in the reviewed sources. Use the official online route, the applicable mailing instructions or a confirmed number supplied with VA's request rather than guessing from another benefit's fax number.

What happens afterward, and common mistakes

VA uses the facility information with the rest of the benefits application to determine eligibility. Completing 21-0779 does not itself enroll a patient in Medicaid, admit someone to a VA facility or guarantee an Aid and Attendance award.

VA's Aid and Attendance page does not promise a fixed decision time. It says claims are processed in the order received unless priority processing applies. Watch for requests for additional information and keep copies of anything supplied in response.

Before sending, check for these avoidable problems:

  • A family member signed where the nursing home official must sign.
  • Medicaid approval for the facility was confused with coverage for the patient.
  • Medicare information was used to answer a Medicaid question.
  • The admission date was copied into the coverage-start field without verification.
  • The full facility charge replaced the patient's own monthly responsibility.
  • The care-level selection or official's contact information was omitted.
  • The facility form was treated as the complete pension application.

21-2680 is the related examination form for Aid and Attendance or Housebound benefits. 21P-527EZ is the Veterans Pension application, while 21P-534EZ covers the relevant survivor-benefit application. Start with VA's pension pages to choose the actual application needed.

If a separate statement is useful, Raven Scribe can help organize your own observations about daily assistance into an editable draft. Distinguish what you personally observed from what a clinician or facility reported. The draft cannot replace the official's certification. The 21-4138 guide explains that supporting-statement form.

Sources and scope

Verified September 25, 2026: VA's form page, both pages of the September 2023 PDF, VA's pension Aid and Attendance instructions and the linked submission route. The scenario is fictional. Mailing instructions differ by the standalone form and application package as explained above. This guide does not calculate pension, Medicaid eligibility or a patient's final benefit amount.

Where to go next

Claim Raven is data analysis, not legal, medical, or VA-accredited advice. Confirm the right benefit application and evidence with VA or an accredited representative.

-Landon Founder, Claim Raven | U.S. Army Veteran