Items 1A to 4: provider
Name and address (name, city, state, county and ZIP), telephone number, Medicare provider number, chain, and whether the provider is licensed or approved by the state in which it is located.
10-1170
Application for Furnishing Long-Term Care to Beneficiaries of Veteran Affairs
- Agency
- VA
- Revision
- November 2006
- Fillable fields
- 34
- Pages
- 2
- Official source
- VA form page
- Checked
- October 20, 2026
VA Form 10-1170: Application for Furnishing Long-Term Care to VA Beneficiaries
VA Form 10-1170 is the U.S. Department of Veterans Affairs Application for Furnishing Long-Term Care Services to Beneficiaries of Veterans Affairs, listed under VHA on VA's page. It is completed by a long-term care provider, not by a Veteran. Its notice says the information is used to determine your qualifications to provide Long-Term Care, and that failure to provide it will delay or prevent approval of your agency.
The two-page form asks for the provider's name, address and Medicare provider number, state licensing and Medicare/Medicaid certification, total capacity and number of clients, the advising physician, the Director of Nursing Service, facility details and an initial and final schedule of services with prices. The provider signs, and the VA Center Director or designee signs on the same page as the provider agreement number and the effective dates of the agreement.
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 10-1170
Items 5 to 8: certification and capacity
Whether the provider is certified for participation in the Medicare/Medicaid program, total capacity, the number of clients on the filing date and the advising physician.
Items 9A to 10B: nursing and facility
The Director of Nursing Service and license details, whether there is an in-service training program for all nursing personnel, the date the facility was built (N/A for home health) and whether there is an automatic fire sprinkler system throughout the facility.
Items 11 to 14: schedules of services
An initial and a final schedule of services by case-mix or level of care, each with an amount (price). The form says to attach additional sheets as necessary.
Items 15A to 20: agreement and signatures
The provider's agreement to furnish and deliver all items set forth subject to the terms and conditions specified, the number of copies required, the provider agreement number, effective dates, both signatures and comments.
How to complete VA Form 10-1170
- 1
Enter the provider details
Fill in Items 1A to 4 with the provider's name, address, telephone, Medicare provider number, chain and state licensing.
- 2
Describe certification, staff and facility
Complete Items 5 to 10B on certification, capacity, clients, the advising physician, the Director of Nursing Service, training, the facility build date and sprinklers.
- 3
List services and prices
Enter the initial and final schedules of services by case-mix or level of care, with the amount for each, and attach additional sheets as necessary.
- 4
Sign and return copies
Item 15A says the provider is requested to sign this document and return the number of copies specified in Item 15B to the issuing office. The signer adds a name, title and date.
- 5
VA signs the agreement
Page 2 holds the provider agreement number, the start and end dates of the agreement and the signature of the VA Center Director or designee.
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Where it goes and edition
Where it goes
Item 15A says to return the signed copies to the issuing office. The form prints no mailing address for the application.
Burden comments address
Comments on the burden estimate go to VHA Clearance Officer (19E1); Department of Veterans Affairs; 810 Vermont Ave. NW; Washington, DC 20420. The form says: DO NOT SEND YOUR APPLICATION TO THIS ADDRESS.
Burden
OMB Number 2900-0616, with an estimated burden of 10 minutes. The notice cites Title 38, Part II, Sections 1710 and 1730.
Edition
NOV 2006 (RS), matching the November 2006 revision date on VA's form page. It supersedes VA Form 10-1170, MAR 2004, which will not be used.
Related forms
10-10171
Veterans Health Administration (VHA) Veterans Care Agreement
13 fields, 16 pages
10-10145
Veterans Health Administration (VHA) Veterans Choice Program Provider Agreement
9 fields, 6 pages
10-10EC
Application for Extended Care Services
62 fields, 4 pages
10-10SH
State Home Program Application for Veteran Care Medical Certification
159 fields, 6 pages
Who uses VA Form 10-1170?
The form names these providers, staff and VA officials.
Official sources and the blank
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Questions about Form 10-1170
Who completes VA Form 10-1170?
A long-term care provider. The form asks for the provider's details and its notice speaks of the approval of your agency to provide Long-Term Care.
What is the information used for?
The notice says it is used to determine your qualifications to provide Long-Term Care, and that failure to provide it will delay or prevent approval of your agency.
What does the schedule of services ask for?
Items 11 to 14 ask for an initial and a final schedule of services by case-mix or level of care, each with an amount (price).
Who signs VA Form 10-1170?
The provider signs Item 18A with a name, title and date, and the VA Center Director or designee signs Item 19A.
Where is VA Form 10-1170 sent?
Item 15A says to return the number of copies specified to the issuing office. The VHA Clearance Officer address on the form is for burden comments only, and the form says not to send the application there.
Which edition is current?
The PDF prints NOV 2006 (RS) and says it supersedes VA Form 10-1170, MAR 2004, which will not be used.