Fillable Printable VA Form 10-1170
Fillable Printable VA Form 10-1170
VA Form 10-1170
Page 1 of 2
VA FORM
NOV 2006 (RS)
10-1170
SUPERSEDES VA FORM 10-1170, MAR 2004, WHICH WILL NOT BE USED.
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.
APPLICATION FOR FURNISHING LONG-TERM CARE
SERVICES TO BENEFICIARIES OF VETERANS AFFAIRS
OMB Number 2900-0616
Estimated Burden: 10 min.
1A. NAME/ADDRESS OF PROVIDER
(Name, City, State, County & Zip)
1B. TELEPHONE NUMBER
2. MEDICARE PROVIDER NO.
3. IF THIS AGENCY IS PART OF
A CHAIN, SPECIFY WHICH ONE
4. IS PROVIDER LICENCED
OR APPROVED BY STATE
IN WHICH LOCATED
YES NO
5. PROVIDER IS CERTIFIED FOR
PARTICIPATION IN MEDICARE/
MEDICAID PROGRAM
YES NO
6. TOTAL CAPACITY
(Specify number)
7. NUMBER OF CLIENTS
ON FILING DATE
8. NAME OF PHYSICIAN WHO ADVISED AGENCY
ON PROFESSIONAL MATTERS
9A. NAME OF DIRECTOR OF NURSING SERVICE
9B. IS DIRECTOR CURRENTLY LICENCED IN
STATE WHERE NURSING HOME IS LOCATED
YES NO
9C. REGISTRATION NO.
9D. IS THERE AN IN-SERVICE TRAINING
PROGRAM FOR ALL NURSING PERSONNEL
YES NO
10A. DATE FACILITY BUILT
(N/A for home health)
10B. IS THERE AN AUTOMATIC FIRE
SPRINKLER SYSTEM THROUGHOUT THE
FACILITY
YES NO
11. INITIAL SCHEDULE OF SERVICES (Case-mix/level of care)
12. AMOUNT (Price)
(Attach additional sheets as necessary.)
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VA FORM
NOV 2006 (RS)
10-1170
SUPERSEDES VA FORM 10-1170, MAR 2004, WHICH WILL NOT BE USED.
13. FINAL SCHEDULE OF SERVICES (Case-mix/level of care)
14. AMOUNT (Price)
APPLICATION FOR FURNISHING LONG-TERM CARE
SERVICES TO BENEFICIARIES OF VETERANS AFFAIRS, CONTINUED
(Attach additional sheets as necessary.)
15A. THE PROVIDER IS REQUESTED TO SIGN THIS DOCUMENT
AND RETURN THE NUMBER OF COPIES SPECIFIED BELOW TO
THE ISSUING OFFICE. PROVIDER AGREES TO FURNISH AND
DELIVER ALL ITEMS SET FORTH OR OTHERWISE IDENTIFIED
ABOVE AND ON ANY ADDITIONAL SHEET SUBJECT TO THE
TERMS AND CONDITIONS SPECIFIED.
15B. NUMBER OF COPIES REQUIRED BY ISSUING OFFICE
16. PROVIDER AGREEMENT NUMBER
17. EFFECTIVE DATES OF AGREEMENT
(Start date/end date)
18A. SIGNATURE OF PROVIDER 19A. SIGNATURE OF VA CENTER DIRECTOR OR DESIGNEE
18B. NAME AND TITLE OF SIGNER
(Type or Print)
18C. DATE SIGNED
19B. NAME OF VA CENTER DIRECTOR OR
DESIGNEE
(Type or Print)
19C. DATE SIGNED
20. COMMENTS
