10-10SH
State Home Program Application for Veteran Care Medical Certification
VA Form 10-10SH is the U.S. Department of Veterans Affairs State Home Program Application for Veteran Care Medical Certification, listed under VHA on VA's page. Its instructions say that, as a condition for a VA approved State Veterans Home (SVH) to receive payment of per diem, the State Home submits to the VA Medical Center of jurisdiction, for each Veteran, a completed VA Form 10-10SH and a 10-10EZ, Application for Health Benefits, or 10-10EZR, Health Benefits Update Form.
The form is completed by staff, not by the Veteran. The instructions assign Parts I and II to State Veterans Home designated staff, Part III to the SVH, Part IV to an SVH Social Worker or Physician/APRN/PA, and Part V, VA Authorization for Payment, to VA Medical Center of Jurisdiction designated staff.
The PDF has six pages: three pages of form and three pages of item by item instructions. You can fill out the PDF free in your browser on this page and download the result without an account.
Items 1 to 10: the State Home facility, date admitted, facility address, resident's name, Social Security number, sex, age, date of birth, advanced medical directive, and whether the Veteran has provided financial disclosure for domiciliary per diem.
Items 11 to 44: history, vital signs, body systems, allergies, x-ray and lab results, dementia and mental health questions, oxygen, feeding, wound and catheter needs, diagnoses, service connection, the type of care recommended and admission orders.
A numbered scale for communication, speech, hearing, sight, transfer, ambulation, endurance, mental and behavior status, toileting, bathing, dressing, feeding, bladder and bowel control, skin condition and wheelchair use, then physical therapy Items 49 to 57.
Prior living arrangements, a long range plan, adjustment to illness or disability, living environment and the ability to make competent decisions, plus remarks.
An administrative review of the 10-10EZ or 10-10EZR, dates and per diem eligibility (Basic, Prevailing or No), and a clinical review of nursing home, domiciliary and adult day health care, each with a VA signature.
Pages 4 to 6 explain each item. Page 3 holds the Paperwork Reduction Act and Privacy Act statement, citing Title 38, U.S.C. Sections 1741, 1743 and 1745.
Enter the facility, admission and resident details. The instructions say N/A in Item 10 is used for admission applications for NHC and ADHC.
The instructions say the form must contain sufficient medical information to justify the level of care. The form notes Item 44 cannot be signed without first filling out Items 36 to 43.
A registered nurse or Physician/APRN/PA signs the evaluation, a therapist or Physician/APRN/PA signs the physical therapy items, and a social worker or Physician/APRN/PA signs Part IV.
The State Home submits the 10-10SH with a 10-10EZ or 10-10EZR to the VA Medical Center of jurisdiction.
VA staff complete the administrative and clinical reviews. The instructions say the VA clinician's signature in block 82 indicates approval of the level of care the SVH physician recommended in block 41.
You get the real form, filled in a browser tab, with nothing standing between you and the finished PDF.
The instructions say the State Home submits it to the VA Medical Center of jurisdiction with a 10-10EZ or 10-10EZR. The form prints no mailing address.
The instructions say to use additional sheets containing the Veteran's name and Social Security Number, and to write Continuation of Item with the section and question number.
Notes on the form say that after each signature, the fields in that part become locked and read only.
The instructions say that if the VA clinician does not agree with the SVH physician's level of care recommendation, per diem is not approved and a denial letter is sent to the State Home with Appeal Rights.
OMB Control No: 2900-0160, Expiration Date: 11-30-2027, with an estimated burden of 20 minutes.
The PDF footer prints FEB 2025 and says previous editions of this form are not to be used. VA's form page lists a revision date of July 2021.
The instructions name who completes each part.
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The instructions say the State Home submits it to the VA Medical Center of jurisdiction for each Veteran, as a condition for a VA approved State Veterans Home to receive payment of per diem.
Yes. The form says a 10-10EZ or 10-10EZR is required to be submitted either in paper form or electronically with the 10-10SH.
State Veterans Home designated staff complete Parts I and II, the SVH completes Part III, an SVH Social Worker or Physician/APRN/PA completes Part IV, and VA Medical Center of Jurisdiction designated staff complete Part V.
Item 41 lists skilled nursing home care, domiciliary care and adult day health care.
The instructions say the VA clinician's signature in block 82 indicates approval of the level of care recommended by the SVH physician in block 41.
The instructions say to use additional sheets with the Veteran's name and Social Security Number, writing Continuation of Item and the section and question number.
The PDF prints FEB 2025 and says previous editions are not to be used.
