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

What VA Form 21-0779 is for

Form 21-0779 verifies nursing home care for a claim involving aid and attendance. VA uses it to decide pension and aid and attendance eligibility based on nursing home status. You fill in whose claim it is and which nursing home; a nursing home official completes the rest and signs.

Need the aid and attendance medical exam form? That is Form 21-2680, which a medical examiner completes. Fill in Form 21-2680.

Parts someone else completes

A nursing home official completes Section IV (items 11 to 19): the admission date, the Medicaid questions, the patient's monthly out-of-pocket amount, the level of care, and the official's name, title and office phone. The official then signs and dates items 20 and 21. A family member's signature does not replace the official's.

What you fill in by hand

The filler never asks for your Social Security number, VA file number, date of birth or signature. You write those in by hand. Leave these boxes for yourself:

• Items 2 and 6: Social Security numbers
• Items 3 and 7: VA file numbers
• Items 4 and 8: dates of birth
• Items 11 to 19
• Items 20 and 21: signature and date

Where to send it

• Give the form to the nursing home official to complete Section IV and sign. Before they sign, compare the admission date, Medicaid dates, monthly amount and level of care with the facility's records.
• Online: VA's form page offers an online route and says to submit a completed PDF through that page.
• By mail, the address printed on the form: Department of Veterans Affairs, Evidence Intake Center, PO Box 4444, Janesville, WI 53547-4444.
• With a mailed aid and attendance pension application, VA's page gives: Department of Veterans Affairs, Pension Intake Center, PO Box 5365, Janesville, WI 53547-5365. Follow that application's instructions.
• Answering a VA request: follow its return instructions. If they seem to conflict with the form, call VA at 800-827-1000 (TTY 711). Keep the acknowledgment with your copy.

Claim Raven does not submit forms to VA. You review the filled PDF, sign and date it, and send it to VA yourself. Claim Raven is independent and is not affiliated with VA.

Official form and guide

• VA's page for Form 21-0779 on VA.gov
• VA Form 21-0779 example and how to fill it out

This filler uses the September 2023 edition of the form.