To and From boxes
The VA facility, and the name and address of the State Home, then a request sentence with a blank for the State Nursing Home's name.
10-0460
Request for Prescription Drugs from an Eligible Veteran in a State Home
- Agency
- VA
- Revision
- November 2020
- Fillable fields
- 76
- Pages
- 3
- Official source
- VA form page
- Checked
- October 20, 2026
VA Form 10-0460: Request for Prescription Drugs from an Eligible Veteran in a State Home
VA Form 10-0460 is the U.S. Department of Veterans Affairs Request for Prescription Drugs from an Eligible Veteran in a State Home, listed under VHA on VA's form page. In it, a Veteran admitted to a State Nursing Home asks to be furnished with prescription drugs by VA as provided for in Title 38 of the Code of Federal Regulations, Section(s) 17.96 and/or 51.42. The form is addressed To a VA facility, From the State Home named with its address.
The form is three pages. Page 1 holds the request, four categories to check, the Veteran's signature and the applicant information. Page 2 lists the diagnoses for which the Veteran was admitted, the prescribing physician and a certification signed by a State Home representative. Page 3 holds the Paperwork Reduction Act and Privacy Act notices.
You can fill out the PDF free in your browser on this page and download the result without an account.
What's on VA Form 10-0460
Categories 1 and 2
A Veteran receiving increased VA compensation or pension for being permanently housebound or needing regular aid and attendance, or a Veteran needing regular aid and attendance whose increased pension was discontinued solely by reason of excess income and whose annual income does not exceed the maximum annual income limitation by more than $1,000.
Categories 3 and 4
Veterans with a singular or combined service-connected rating of 50 or 60 percent, or of less than 50 percent, each with the conditions the form prints about the need for drugs and for nursing home care.
Signature and applicant information
Signature of the Veteran and date of application, then the Veteran's name, Social Security number, date of admission to the State Nursing Home, the date A&A or Housebound was awarded by VA and whether a copy of the award is attached.
Page 2: diagnoses and certification
Diagnosis code and name for each diagnosis for which the applicant was admitted, the category of eligibility from page 1, the prescribing physician, and a certification that the listed medications are prescribed for the Veteran.
Page 3: notices
The Paperwork Reduction Act notice, which estimates 30 minutes per response and cites Title 38 CFR Parts 51 and 58, and the Privacy Act information, which names system of records 24VA136.
How VA Form 10-0460 is completed
- 1
Fill in the To and From boxes
Enter the VA facility, the name and address of the State Home, and the State Nursing Home's name in the request sentence.
- 2
Check the categories that apply
The form says to check any of the four categories listed on page 1.
- 3
Sign and add applicant information
The Veteran signs and dates the request. Then enter the Veteran's name, Social Security number, admission date, the A&A or Housebound award date, and mark whether a copy of the award is attached.
- 4
Complete page 2
List each admitting diagnosis code and name, the category of eligibility from page 1 (1, 2, 3 or 4), and the prescribing physician's name and telephone number.
- 5
State Home certification
A State Home representative signs the certification that the medications that follow are prescribed for the Veteran named.
Why fill Form 10-0460 on indox
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Where it goes and edition
Where it goes
The form is addressed To the VA facility, From the State Home. It prints no mailing address or fax number.
Award copy
Page 1 asks whether a copy of the A&A or Housebound award is or is not attached with the request.
OMB details
Page 1 prints OMB Control No. 2900-0883, an estimated burden of 30 minutes and an expiration date of 11/30/2023.
Edition
The footer reads VA FORM NOV 2020. VA's form page lists a revision date of February 2008.
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28 fields, 1 page
Who uses VA Form 10-0460?
The form names the people and places involved in the request.
Official sources and the blank
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Questions about Form 10-0460
What is VA Form 10-0460 used for?
A Veteran admitted to a State Nursing Home uses it to request that VA furnish prescription drugs, as provided for in Title 38 of the Code of Federal Regulations, Section(s) 17.96 and/or 51.42.
Who signs VA Form 10-0460?
The Veteran signs page 1 as the Veteran Applying for Benefit. A State Home representative signs the medication certification on page 2.
What categories does the form list?
Four. Categories 1 and 2 relate to increased VA compensation or pension for being housebound or needing aid and attendance. Categories 3 and 4 relate to service-connected ratings of 50 or 60 percent, or less than 50 percent.
Does the form ask about an Aid and Attendance or Housebound award?
Yes. It asks the date A&A or Housebound was awarded by VA and whether a copy of the award is or is not attached with the request.
Which diagnoses go on page 2?
The diagnosis or diagnoses for which the applicant was admitted to the State Nursing Home, each with a diagnosis code and name, plus the category of eligibility from page 1.
Is giving the Social Security number optional?
The Privacy Act information says disclosure is voluntary but the information is required to determine eligibility, and that disclosure of Social Security numbers is requested under the authority of Title 38, U.S.C., and is mandatory.
Which edition is this?
The PDF footer reads VA FORM NOV 2020. VA's form page lists a revision date of February 2008.