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)

• ×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.

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)

• ×Administrator leaving the duration field blank - VA may treat the placement as temporary and limit the A&A award period.

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)

• ×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.