Sections I and II: identification
The Veteran's name, Social Security number, VA file number and date of birth, and the same details for the claimant when the claimant is not the Veteran.
21-0779
Request for Nursing Home Information in Connection with Claim for Aid and Attendance
- Agency
- VA
- Revision
- September 2023
- Fillable fields
- 51
- Pages
- 2
- Official source
- VA form page
- Checked
- October 20, 2026
VA Form 21-0779: Request for Nursing Home Information for Aid and Attendance
VA Form 21-0779 is the U.S. Department of Veterans Affairs Request for Nursing Home Information in Connection with Claim for Aid and Attendance. VA's form page says to use it 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. The form says VA uses it to determine eligibility for pension and aid and attendance benefits based on nursing home status.
The form is two pages. Sections I and II identify the Veteran and, only when the claimant is not the Veteran, the claimant. Section III names the nursing home, Section IV is to be completed by a nursing home official, and Section V holds the official's certification and signature. Page 2 holds the Privacy Act and Respondent Burden notices.
VA's page says the form can also be filled out online. 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 21-0779
Section III: nursing home
The name and full address of the nursing home.
Items 11 to 14B: admission and Medicaid
The date admitted, whether the home is a Medicaid approved facility, whether the patient applied for and is covered by Medicaid, and the date the Medicaid plan began. The form notes that a state's Medicaid program may use a different name.
Items 15 and 16: costs and level of care
The monthly amount the patient is responsible for out of pocket, and a certification that the claimant is a patient because of mental or physical disability and is receiving skilled or intermediate nursing care.
Items 17 to 21: the official
The nursing home official's name, title and office phone number, a certification that the statements are true and correct, the required signature and the date signed.
How VA Form 21-0779 is filed
- 1
Read the notices on page 2
The form says to read the Privacy Act and Respondent Burden on page 2 before completing it.
- 2
Identify the Veteran and the claimant
Fill in Section I, Section II only when the claimant is not the Veteran, and the nursing home in Section III. By hand, the form asks for neat, legible printing in ink.
- 3
The official completes Section IV
The nursing home official answers the admission, Medicaid, out of pocket and level of care items and adds their name, title and phone.
- 4
The official signs Section V
The official signs Item 20, which the form marks required, and enters the date in Item 21.
- 5
Submit online or mail it
VA's page says to submit the completed PDF on that page, fill out the form online instead, or print it and mail it to the address on the form.
Why fill Form 21-0779 on indox
You get the real form, filled in a browser tab, with nothing standing between you and the finished PDF.
- Fill the form right in your browser, no software to install
- Free to fill and free to download, with no account
- The official blank straight from the VA, not a copy someone retyped
- Works on a phone, tablet or computer
Where to send it and getting help
Online
VA's form page says you can fill out this form online instead of filling out and sending the paper form, or download the PDF, fill it out and submit it on that page.
By mail
Department of Veterans Affairs, Evidence Intake Center, P.O. Box 4444, Janesville, WI, 53547-4444.
Questions
The form points to Ask VA at https://ask.va.gov and the toll-free number 1-800-827-1000 (TTY:711).
Edition
The SEP 2023 edition supersedes VA Form 21-0779, AUG 2020. It carries OMB Approved No: 2900-0652, which expires 09/30/2026, and a respondent burden of 10 minutes.
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21-4138
Statement in Support of Claim (VA Form 21-4138)
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21-0845
Authorization to Disclose Personal Information to a Third Party (VA Form 21-0845)
57 fields, 3 pages
Who completes VA Form 21-0779?
The form is completed and signed by a nursing home official, not by the Veteran.
Official sources and the blank
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Questions about Form 21-0779
Who fills out VA Form 21-0779?
VA's form page says to use it if you're a nursing home official. Section IV is to be completed by a nursing home official, who also signs Item 20.
What is the form used for?
The form says VA uses it to determine eligibility for pension and aid and attendance benefits based on nursing home status.
Can VA Form 21-0779 be completed online?
Yes. VA's form page says you can fill out this form online instead of filling out and sending the paper form.
When is Section II filled in?
Only if the claimant is not the Veteran. It asks for the claimant's name, Social Security number, VA file number if applicable and date of birth.
What does the form ask about Medicaid?
Whether the nursing home is a Medicaid approved facility, whether the patient has applied for Medicaid, whether the patient is covered, and if so the date the Medicaid plan began.
Which levels of care does the form list?
Item 16 asks the official to check one: skilled nursing care or intermediate nursing care.
Where is VA Form 21-0779 mailed?
The form lists Department of Veterans Affairs, Evidence Intake Center, P.O. Box 4444, Janesville, WI, 53547-4444.