About VA Form 21-0779
- Form name: Request for Nursing Home Information in Connection with Claim for Aid and Attendance
- Form revision date: September 2023
- Related to: Disability
When to use this form
Use this form if you’re a nursing home official to verify a Veteran or someone connected to a Veteran is a patient in a qualifying extended care facility.
Download form
Download this PDF form and fill it out. Then submit your completed form on this page. Or you can print the form and mail it to the address listed on the form.
Online tool
You can fill out this form online instead of filling out and sending us the paper form.
Related forms and instructions
VA Form 21-2680
Form name: Examination for Housebound Status or Permanent Need for Regular Aid and Attendance
Use VA Form 21-2680 to apply for Aid and Attendance benefits that will be added to your monthly compensation or pension benefits.
Helpful links related to VA Form 21-0779
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If you need help with daily activities, or you’re housebound, learn about these benefits and if you qualify.