Fillable Printable VA Form 10-5588A
Fillable Printable VA Form 10-5588A
VA Form 10-5588A
TOTAL AMOUNT APPROVED BY VA FOR RETROACTIVE PAYMENT
CLAIM FOR PAYMENT FOR NURSING HOME CARE
PROVIDED TO VETERANS AWARDED
RETROACTIVE SERVICE CONNECTION
OMB No. 2900-0160
Est. Burden: 20 minutes
Expiration Date: February 28, 2019
GENERAL INFORMATION
RETROACTIVE CLAIM INFORMATION
VA FORM
APR 2016
10-5588A
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PREVIOUS EDITIONS OF THIS FORM ARE NOT TO BE USED
19. REMARKS
I certify that this report is correct, that all residents included in the report were physically present during the period for which Federal Aid is claimed,
except for authorized absences for which the VA paid per diem.
20. SIGNATURE OF SVH
ADMINISTRATOR
21. SIGNATURE OF SVH EMPLOYEE
WHEN APPLICABLE
22. SIGNATURE OF VA STATE HOME
APPROVING OFFICIAL
ACCOUNTING CERTIFICATION - AUDIT BLOCK
26. SIGNATURE OF AUDITOR
VETERAN INFORMATION
All Veterans under VA contract with SVHs are not authorized for retroactive Per Diem payment
PAPERWORK REDUCTION ACT OF 1995 AND PRIVACY ACT STATEMENT
The Paperwork Reduction Act of 1995 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 must complete this form will
average 20 minutes. This includes the time it will take to read instructions, gather the necessary facts and fill out the form. Although completion of this form is voluntary, VA will be unable to provide reimbursement for
services rendered without a completed form. Failure to complete the form will have no effect on any other benefits to which you maybe entitled. This information is collected under the authority Of Title 38 CFR Parts
51 and 52. The information requested on this form is solicited under the authority of Title 38, U.S.C., Sections 1741, 1742 and 1743. It is being collected to enable us to determine your eligibility for medical benefits in
the State Home Program and will be used for that purpose. The income and eligibility you supply may be verified through a computer matching program at any time and information may be disclosed outside the VA as
permitted by law; possible disclosures include those described in the "routine uses" identified in the VA system of records 24VA136, Patient Medical Record-VA, published in the Federal Register in accordance with the
Privacy Act of 1974. Disclosure is voluntary; however, the information is required in order for us to determine your eligibility for the medical benefit for which you have applied. Failure to furnish the information will
have no adverse affect on any other benefits to which you may be entitled. Disclosure of Social Security number(s) of those for whom benefits are claimed is requested under the authority of Title 38, U.S.C., and is
voluntary. Social Security numbers will be used in the administration of veterans benefits, in the identification of veterans or persons claiming or receiving VA benefits and their records and may be used for other
purposes where authorized by Title 38, U.S.C., and the Privacy Act of 1974 (5 U.S.C. 552a) or where required by other statute.
1. VISN
8. PAY TO
6. TO
(Enter VA Facility) 7. FROM (Enter Name & Address of State Home)
2. STATION NUMBER
3. FOR MONTH ENDING
4. REPORT QUARTER 5. FISCAL YEAR
9. Name and
Last 4 of SSN
(a)
10. Month
and Year
(b)
11. Days of
Care
Claimed
(c)
12. Basic Per
Diem Rate
Paid
(d)
13. Total
Amount
Claimed
(e)
14. Daily Cost
of Care
Claimed
(f)
15. FY
Prevailing
Per Diem Rate
(g)
16. Amount Claimed
at the Service
Connected Rate
(h)
17. Amount
Due
(i)
18. Total Per Diem Claimed
PRINTED NAME AND TITLE:
SIGNATURE: DATE:
PRINTED NAME AND TITLE:
SIGNATURE: DATE:
PRINTED NAME AND TITLE:
SIGNATURE: DATE:
25. DATE24. AMOUNT DUE23. CONTROL NUMBER
PRINTED NAME AND TITLE:
SIGNATURE: DATE:
27. Name of Veteran
(a)
28. Last 4-Digit
of SSN
(b)
29. SC Award
Effective Date
(c)
30. SC Disability
(d)
31. SC Rating
(e)
INSTRUCTION SHEET: VA FORM 10-5588A
CLAIM FOR PAYMENT FOR NURSING HOME CARE PROVIDED TO VETERANS AWARDED RETROACTIVE SERVICE CONNECTION
Completion of this form is optional and intended to reduce burden hours for State Homes claiming retroactive State Home Per Diem payments.
Completed by: Veteran Affairs Employees
1. VISN-
Enter the Veterans Integrated Service Networks (VISN)
2. Station Number-Enter the station number where the VA Medical Center of Jurisdiction is located.
Completed by: State Home Employees
3. Month Ending-Enter the month and year for the report e.g., Oct 2012.
4. Report Quarter-Enter the Federal fiscal quarter the report is for. The Federal fiscal year starts on October 1st, which is the first day of the 1st.
Quarter.
**A completed 10-5588A form is requested in addition to VA Form 10-5588 for eligible Veterans in the SVH for which a retroactive claim is being
requested. Do not claim days of care for which the Veteran is not present in the facility unless the Veteran is on VA approved paid bed hold for
overnight hospital stay or non-hospital leave. Do not claim days of care when the facility's daily occupancy rate is below 90 percent.
**The VA recommends that the State Veteran home submit with the retroactive payment a letter indicating they have or will reimburse any payer sources
they have collected from on behalf of the Veteran.
5. Fiscal Year-The claim period is based on a Federal Fiscal year from September to October.
6. To-Enter the name and address of the VA Medical Center of Jurisdiction.
7. From-Enter the name of State Home and address.
8. Pay to-Enter the name and address where the payment is to be sent
RETROACTIVE CLAIM INFORMATION
12. Fiscal Year Basic Per Diem Rate Paid, column (d) - enter the basic per diem rate claimed on 15(h) on the original 10-5588 claim.
11. Days of Care Claimed, column (c) - enter the number of days of care per diem is being claimed.
10. Month and Year of Claim, column (b) - enter the month and fiscal year for the month being claimed.
9. Name and last four, column (a) - enter the first initial of the last name and the last four digits of the Veteran's social security number.
14. Daily Cost of Care Claimed, column (f) - enter the daily cost of care reported on the original 10-5588. If the SVH used an average daily cost of care
or allowable cost from the prior year in the original 10-5588 claim when completing this retroactive form, enter the actual daily cost of care and
provide supporting documentation to support this claim. If filing for a retroactive payment for periods after February 1, 2013 leave this block blank as
the prevailing rate will be paid rather than the lesser of either the daily cost of care or prevailing rate.
13. Total Fiscal Year Basic Rate Claimed, column (e) - Multiply column (c) times column (d).
16. Amount Claimed at the Service Connected Rate, column (h) - If the retroactive claim is for a period prior to February 2, 2013, multiply column (c)
(days of care) by the lesser of either columns (f) (daily cost of care claimed) or (g) (prevailing per diem rate). For retroactive claims from February 2,
2013 forward, leave column (f) (daily cost of care) blank and multiply column (c) (days of care) by column (g) (prevailing per diem rate). Note: All
per diem paid after February 2, 2013 should be the prevailing rate times the days of care.
15. Fiscal Year Prevailing Rate, column (g) - enter the prevailing rate for the Fiscal year for which the retroactive claim is being requested.
19. Remarks- provide any supporting comments regarding the claims above
18. Total Amount - Add column (i)
17. Amount Due - Subtract column (e) (total amount claimed) from column (h). (amount claimed at the service connected rate)
CERTIFICATION OF STATE HOME PERSONNEL
21. Signature of State Veteran Home Employee when Applicable
20. Signature of State Veteran Home Administrator
23. Control Number
22. Signature of VA State Home Approving Official
24. Amount Due
CERTIFICATION BY CONTRACTING OFFICER OR AGREEMENT COORDINATOR
29. Service Connected Award Date - enter the effective date of service connected rating.
28. SSN - enter the last four digit of Social Security Number of the Veteran.
27. Name of Veteran- Enter the last name, first name and middle initial.
31. Service Connected Rating - enter the new SC awarded.
30. Service Connected (SC) Disability - enter the medical condition for the increase in SC.
VETERAN INFORMATION
VA FORM
APR 2016
10-5588A
PREVIOUS EDITIONS OF THIS FORM ARE NOT TO BE USED
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