Application For Furnishing Long-Term Care Services To Beneficiaries Of Veterans Affairs
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1
2OMB Number 2900-0616
Estimated Burden: 10 min.
APPLICATION FOR FURNISHING LONG-TERM CARE
SERVICES TO BENEFICIARIES OF VETERANS AFFAIRS
The Paperwork Reduction Act requires us to notify you that this information collection is in accordance with the clearance requirements of
section 3507 of the Paperwork Reduction Act of 1995. We may not conduct or sponsor and you are not required to respond to a collection of
information unless it displays a valid OMB number. We anticipate that the time expended by all individuals who complete this form will
average 10 minutes. This includes the time it will take to read instructions, gather the necessary facts and complete the form. This
information is collected under the authority of Title 38, Part II, Sections 1710 and 1730. This information is used to determine your
qualifications to provide Long-Term Care. Although this information is voluntary, failure to provide it will delay or prevent our approval of
your agency.
Comments regarding this burden estimate or any other aspect of this collection, including suggestions for reducing the burden may be sent to
VHA Clearance Officer (19E1); Department of Veterans Affairs; 810 Vermont Ave. NW; Washington, DC 20420. DO NOT SEND YOUR APPLICATION TO
THIS ADDRESS.
4. IS PROVIDER LICENCED
1B. TELEPHONE NUMBER
1A. NAME/ADDRESS OF PROVIDER
3. IF THIS AGENCY IS PART OF
OR APPROVED BY STATE
(Name, City, State, County & Zip)
A CHAIN, SPECIFY WHICH ONE
IN WHICH LOCATED
2. MEDICARE PROVIDER NO.
YES
NO
5. PROVIDER IS CERTIFIED FOR
8. NAME OF PHYSICIAN WHO ADVISED AGENCY
6. TOTAL CAPACITY
7. NUMBER OF CLIENTS
PARTICIPATION IN MEDICARE/
ON PROFESSIONAL MATTERS
(Specify number)
ON FILING DATE
MEDICAID PROGRAM
YES
NO
9B. IS DIRECTOR CURRENTLY LICENCED IN
9A. NAME OF DIRECTOR OF NURSING SERVICE
9C. REGISTRATION NO.
STATE WHERE NURSING HOME IS LOCATED
YES
NO
9D. IS THERE AN IN-SERVICE TRAINING
10B. IS THERE AN AUTOMATIC FIRE
10A. DATE FACILITY BUILT
PROGRAM FOR ALL NURSING PERSONNEL
SPRINKLER SYSTEM THROUGHOUT THE
(N/A for home health)
FACILITY
YES
NO
YES
NO
(Case-mix/level of care)
(Price)
11. INITIAL SCHEDULE OF SERVICES
12. AMOUNT
(Attach additional sheets as necessary.)
VA FORM
10-1170
SUPERSEDES VA FORM 10-1170, MAR 2004, WHICH WILL NOT BE USED.
Page 1 of 2
NOV 2006 (RS)
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