Free VA Form 10-1170 - Application for Furnishing Nursing Home Care to Beneficiaries of VA- fillable - Federal


File Size: 619.6 kB
Pages: 2
File Format: PDF
State: Federal
Category: Veterans Forms
Word Count: 526 Words, 3,271 Characters
Page Size: Letter (8 1/2" x 11")
URL

http://www.va.gov/vaforms/medical/pdf/vha-10-1170-fill.pdf

Download VA Form 10-1170 - Application for Furnishing Nursing Home Care to Beneficiaries of VA- fillable ( 619.6 kB)


Preview VA Form 10-1170 - Application for Furnishing Nursing Home Care to Beneficiaries of VA- fillable
OMB Number 2900-0616 Estimated Burden: 10 min.

APPLICATION FOR FURNISHING LONG-TERM CARE SERVICES TO BENEFICIARIES OF VETERANS AFFAIRS
The Paperwork Reduction Act requires us to notify you that this information collection is in accordance with the clearance requirements of section 3507 of the Paperwork Reduction Act of 1995. We may not conduct or sponsor and you are not required to respond to a collection of information unless it displays a valid OMB number. We anticipate that the time expended by all individuals who complete this form will average 10 minutes. This includes the time it will take to read instructions, gather the necessary facts and complete the form. This information is collected under the authority of Title 38, Part II, Sections 1710 and 1730. This information is used to determine your qualifications to provide Long-Term Care. Although this information is voluntary, failure to provide it will delay or prevent our approval of your agency. Comments regarding this burden estimate or any other aspect of this collection, including suggestions for reducing the burden may be sent to

VHA Clearance Officer (19E1); Department of Veterans Affairs; 810 Vermont Ave. NW; Washington, DC 20420. DO NOT SEND YOUR APPLICATION TO THIS ADDRESS. 1A. NAME/ADDRESS OF PROVIDER 1B. TELEPHONE NUMBER 3. IF THIS AGENCY IS PART OF 4. IS PROVIDER LICENCED A CHAIN, SPECIFY WHICH ONE OR APPROVED BY STATE (Name, City, State, County & Zip) IN WHICH LOCATED 2. MEDICARE PROVIDER NO. YES 5. PROVIDER IS CERTIFIED FOR PARTICIPATION IN MEDICARE/ MEDICAID PROGRAM YES NO 9B. IS DIRECTOR CURRENTLY LICENCED IN STATE WHERE NURSING HOME IS LOCATED YES 9D. IS THERE AN IN-SERVICE TRAINING PROGRAM FOR ALL NURSING PERSONNEL YES NO 10A. DATE FACILITY BUILT NO 10B. IS THERE AN AUTOMATIC FIRE SPRINKLER SYSTEM THROUGHOUT THE FACILITY YES NO 12. AMOUNT (Price) 9C. REGISTRATION NO. 6. TOTAL CAPACITY 7. NUMBER OF CLIENTS (Specify number) ON FILING DATE NO

8. NAME OF PHYSICIAN WHO ADVISED AGENCY ON PROFESSIONAL MATTERS

9A. NAME OF DIRECTOR OF NURSING SERVICE

(N/A for home health)

11. INITIAL SCHEDULE OF SERVICES (Case-mix/level of care)

(Attach additional sheets as necessary.)
VA FORM NOV 2006 (RS)

10-1170

SUPERSEDES VA FORM 10-1170, MAR 2004, WHICH WILL NOT BE USED.

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APPLICATION FOR FURNISHING LONG-TERM CARE SERVICES TO BENEFICIARIES OF VETERANS AFFAIRS, CONTINUED
13. FINAL SCHEDULE OF SERVICES (Case-mix/level of care) 14. AMOUNT (Price)

(Attach additional sheets as necessary.)

15A. THE PROVIDER IS REQUESTED TO SIGN THIS DOCUMENT 16. PROVIDER AGREEMENT NUMBER AND RETURN THE NUMBER OF COPIES SPECIFIED BELOW TO THE ISSUING OFFICE. PROVIDER AGREES TO FURNISH AND DELIVER ALL ITEMS SET FORTH OR OTHERWISE IDENTIFIED ABOVE AND ON ANY ADDITIONAL SHEET SUBJECT TO THE 17. EFFECTIVE DATES OF AGREEMENT (Start date/end date) TERMS AND CONDITIONS SPECIFIED.
15B. NUMBER OF COPIES REQUIRED BY ISSUING OFFICE 18A. SIGNATURE OF PROVIDER 19A. SIGNATURE OF VA CENTER DIRECTOR OR DESIGNEE

18B. NAME AND TITLE OF SIGNER

(Type or Print)

18C. DATE SIGNED 19B. NAME OF VA CENTER DIRECTOR OR DESIGNEE (Type or Print)

19C. DATE SIGNED

20. COMMENTS

VA FORM NOV 2006 (RS)

10-1170

SUPERSEDES VA FORM 10-1170, MAR 2004, WHICH WILL NOT BE USED.

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