VA Form 10-2409: Patient's Agreement with Hospital in Relation to Home Other Than His Own

VA Form 10-2409 is the U.S. Department of Veterans Affairs Patient's Agreement with Hospital in Relation to Home Other Than His Own. VA's form page lists it under VHA. In the agreement, the Veteran agrees to pay a monthly amount, entered in Item 7, to the payee named in Item 8 for room, board, laundry, and attention to the Veteran's welfare.

The Veteran also agrees to discuss any matter of concern that comes up during the agreement with the payee and with the social worker named on the form before making any change in the agreement. The Veteran signs, and the social worker signs as a witness.

The form is one page with 15 items covering the VA station, the Veteran, the payee, the social worker and two signature and date blocks. It does not print an amount. You can fill out the PDF free in your browser on this page and download the result without an account.

Top of page 1 of VA Form 10-2409: Patient's Agreement with Hospital in Relation to Home Other Than His Own, as printed by VA

What's on VA Form 10-2409

Items 1 to 3: VA station

Name of the VA station, its address and telephone number.

Items 4 to 7: Veteran

Name of the Veteran, Social Security number, claim number and the amount the Veteran agrees to pay monthly.

Items 8 to 11: payee and social worker

The payee's name, address and telephone, and the name of the social worker.

Agreement

The Veteran agrees to pay the Item 7 amount monthly to the Item 8 payee for room, board, laundry, and attention to the Veteran's welfare, and to discuss any matter of concern with the payee and the social worker before making any change.

Items 12 to 15: signatures

Signature of the Veteran and date, then the signature of the social worker as witness and date.

How to fill out VA Form 10-2409

1
Enter the VA station
Fill in Items 1 to 3 with the VA station's name, address and telephone number.
2
Fill in the Veteran's details
Enter the Veteran's name, Social Security number and claim number in Items 4 to 6.
3
Enter the monthly amount
Item 7 holds the monthly amount the Veteran agrees to pay. The form leaves it blank.
4
Name the payee and social worker
Enter the payee's name, address and telephone in Items 8 to 10 and the social worker's name in Item 11.
5
Sign and witness
The Veteran signs Item 12 and dates Item 13. The social worker signs Item 14 as witness and dates Item 15.

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Where it goes and other details

Where to send it

The form and VA's page do not print a mailing address. Items 1 to 3 name the VA station, and Item 11 names the social worker.

Monthly amount

Item 7 is a blank field. The form does not print an amount or rate.

Edition

The PDF is dated JUN 1997 and says existing stock of VA Form 10-2409, JUN 1996, will be used. VA's form page lists a revision date of May 1997.

Who uses VA Form 10-2409?

The Veteran
Items 4 to 7 hold the Veteran's name, Social Security number, claim number and the monthly amount the Veteran agrees to pay. The Veteran signs Item 12 and dates Item 13.
The payee
Items 8 to 10 name the payee who receives the monthly payment, with an address and telephone number.
The social worker
Item 11 names the social worker, who signs Item 14 as witness and dates Item 15. The Veteran agrees to discuss concerns with this social worker before changing the agreement.
The VA station
Items 1 to 3 give the name, address and telephone number of the VA station.

The form names four parties.

Official sources and the blank

Official VA form page
The agency’s own page for Form 10-2409.
Blank PDF
The official blank form, to print or fill by hand.

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Questions about Form 10-2409

What is VA Form 10-2409?

A one-page agreement in which the Veteran agrees to pay a monthly amount to a named payee for room, board, laundry, and attention to the Veteran's welfare in a home other than the Veteran's own.

Who signs VA Form 10-2409?

The Veteran signs Item 12. The social worker named in Item 11 signs Item 14 as witness.

Does the form set the monthly amount?

No. Item 7, Agree to Pay Monthly, is a blank field. The form prints no amount.

What does the Veteran agree to besides payment?

To discuss any matter of concern that arises during the agreement with the payee and with the social worker named on the form before making any change in the agreement.

Which edition is on VA's page?

The PDF is dated JUN 1997. The form says existing stock of the JUN 1996 edition will be used.

VA Form 10-2409: Patient's Agreement with Hospital in Relation to Home Other Than His Own