VA Form 21-0779
Request for Nursing Home Information in Connection with Claim for Aid and Attendance
You are a veteran living in a nursing home and claiming Aid and Attendance benefits for which nursing home residency is one of the qualifying criteria.
- Who fills it
- nursing-home-admin
- Journey phase
- Filing Your Claim
- Estimated time
- 10-20 minutes for the veteran to obtain and review; 20-40 minutes for the nursing home to complete.
- When to file
- With the A&A claim. The nursing home administrator must complete and sign the form before you submit it to VA.
Official VA form page: https://www.va.gov/find-forms/about-form-21-0779/
Gather before you start
- ▸Nursing home name, address, phone, and administrator contact
- ▸Your admission date and current room assignment
- ▸The level of care you receive (skilled nursing, custodial, memory care)
- ▸Whether your stay is expected to be permanent or temporary
Attach with the form
- ▸Completed VA Form 21-0779 (nursing home administrator signs)
- ▸VA Form 21-2680 (physician examination for A&A) - submit together
What to Ask the Nursing Home Administrator
Brief 1Information the administrator must provide
Ask the nursing home administrator or social worker to complete and sign VA Form 21-0779. They need to provide: (1) Facility name, address, and license number; (2) Your admission date; (3) Whether your placement is indefinite or temporary and the expected duration; (4) The level of care you receive (skilled nursing, intermediate care, or custodial care); (5) Whether you require daily assistance with activities of daily living; (6) Whether the facility is VA-approved or licensed by the state.
(give this form to the nursing home social worker or administrator)
Common mistakes
- ×Only getting a resident signature when the form requires an administrator or social worker signature - VA requires the facility representative, not the resident.
- ×Forgetting to ask the administrator to describe the level of care - "skilled nursing" vs "custodial" affects A&A determinations.
Authority
- 38 CFR 3.351 - A&A and housebound criteria for pension recipients.
- 38 CFR 3.352 - What counts as needing regular aid and attendance.
Documenting Permanency
Brief 2Ask the administrator to specify whether placement is permanent
VA gives greater weight to nursing home placements that are expected to be permanent or indefinite. Ask the administrator to state in the form whether your placement is expected to be permanent. If it is temporary (e.g., post-surgery rehabilitation), VA may award A&A only for the period of nursing home residency.
(remind administrator to note permanency)
Common mistakes
- ×Administrator leaving the duration field blank - VA may treat the placement as temporary and limit the A&A award period.
Authority
- 38 CFR 3.351 - A&A and housebound criteria for pension recipients.
Before Submitting to VA
ChecklistVerify the form is complete before sending to VA
Before sending the form to VA, check: (1) Administrator signed and dated the form with their title, (2) Facility license number is included, (3) Your admission date is accurate, (4) Level of care is documented, (5) Duration/permanency is stated, (6) The form is paired with VA Form 21-2680 (physician examination) and your A&A claim (21-526EZ or 21P-527EZ).
(review before submitting)
Common mistakes
- ×Submitting 21-0779 without the primary claim form (21-526EZ or 21P-527EZ) - the nursing home certification is evidence, not the claim itself.
- ×Missing 21-2680 - nursing home residency alone satisfies one A&A criterion, but a physician examination is still typically required.
Statutory and regulatory authority
- 38 CFR 3.351 - A&A and housebound criteria for pension recipients.
- 38 CFR 3.352 - What counts as needing regular aid and attendance.
- 38 USC 1114 - Statutory authority for SMC categories including Aid and Attendance and Housebound.