PATIENT'S AGREEMENT WITH HOSPITAL IN RELATION TO A HOME OTHER THAN HIS OWN
1. NAME OF VA STATION 2. ADDRESS 3. TELEPHONE NO.
4. NAME OF VETERAN
5. SOCIAL SECURITY NO.
6. CLAIM NO.
7. AGREE TO PAY MONTHLY
8. NAME OF PAYEE
11. NAME OF SOCIAL WORKER
AGREEMENT: I agree to pay monthly the amount specified in Item No. 7 to the Payee named in Item No. 8 for room, board, laundry, and attention to my welfare. I further agree to discuss any matter of concern to me that arises during the course of this agreement with the Payee and with the Social Worker named above before I make any change in this agreement.
12. SIGNATURE OF VETERAN 13. DATE
14. SIGNATURE OF SOCIAL WORKER (WITNESS)
VA FORM JUN 1997
EXISITNG STOCK OF VA FORM 10-2409, JUN 1996, WILL BE USED.