VETERANS AID AND ATTENDANCE FORM

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To maximize efficiency, family or facility staff is empowered to fill in appropriate answers. Some answers are pre-filled with common answers, but any incorrect statements should be removed. Provider will review and confirm before they sign.
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Email where you would like the completed form sent. It will be returned with password protection, password is Family!23
example@example.com
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1. VETERAN'S NAME (First)
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1. VETERAN'S NAME ( Middle Initial)
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1. VETERAN'S NAME (Last)
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2. SOCIAL SECURITY NUMBER (First 3 Numbers)
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2. SOCIAL SECURITY NUMBER(Next 2 Numbers)
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2. SOCIAL SECURITY NUMBER(Last 4 Numbers)
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3. VA FILE NUMBER (If applicable)
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4. DATE OF BIRTH (MM)
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4. DATE OF BIRTH (DD)
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4. DATE OF BIRTH (YYYY)
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5. VETERAN'S SERVICE NUMBER (If applicable)
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6. SEX
MALE
FEMALE
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TELEPHONE NUMBER (Area Code)
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TELEPHONE NUMBER (First 3 Numbers)
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TELEPHONE NUMBER (Last 4 Numbers)
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8. E-MAIL ADDRESS (Optional)
example@example.com
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Preferred Mailing Address No. & Street
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Apt./Unit Number
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City
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State/Province
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Country
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ZIP Code/Postal Code
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10. CLAIMANT'S NAME (First) (Complete only if you are not the veteran)
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10. CLAIMANT'S NAME ( Middle Initial) (Complete only if you are not the veteran)
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10. CLAIMANT'S NAME (Last) (Complete only if you are not the veteran)
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11. CLAIMANT'S SOCIAL SECURITY NUMBER
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11. CLAIMANT'S SOCIAL SECURITY NUMBER
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11. CLAIMANT'S SOCIAL SECURITY NUMBER
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12. RELATIONSHIP OF CLAIMANT TO VETERAN
SPOUSE
SELF
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No.
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Apt./Unit Number
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City
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State/Province
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Country
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ZIP Code/Postal Code
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14. BENEFIT YOU ARE APPLYING FOR (Choose One)
Special Monthly Compensation SMC - Veterans and surviving spouses or parents who are eligible to receive VA compensation due to a service-related disability or death and require aid and attendance of another person to perform personal functions required in everyday living such as bathing, feeding, dressing, attending to the wants of nature, adjusting prosthetic devices, or protecting oneself from the hazards of the daily environment may be eligible for Special Monthly Compensation. A Veteran or a deceased Veteran's surviving spouse may also be eligible for Special Monthly Compensation based on being housebound substantially confined to the immediate premises because of permanent disability For a Veteran, the disability causing the need for aid and attendance or housebound status must be related to service. These benefits are paid in addition to monthly compensation. They are not paid without eligibility to compensation.
Special Monthly Pension SMP - Veterans and survivors who are eligible for Veteran's Pension and/or Survivors benefits and require the aid and attendance of another person in order to perform personal functions required in everyday living, such as bathing, feeding, dressing, attending to the wants of nature, adjusting prosthetic devices, or protecting him/her from the hazards of his/her daily environment, or are housebound substantially confined to his/her immediate premises because of permanent disability, may be eligible for Special Monthly Pension SMPThis benefit is an increased monthly amount paid to a Veteran or survivor who is eligible for Veterans Pension or Survivors benefits.
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15. DATE OF PROVIDER EXAMINATION (MM)
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15. DATE OF PROVIDER EXAMINATION (DD)
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15. DATE OF PROVIDER EXAMINATION (YYYY)
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16A. Is Claimant Hospitalized?
YES
NO
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16B. DATE ADMITTED (MM)
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16B. DATE ADMITTED (DD)
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16B. DATE ADMITTED (YYYY)
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17A. NAME OF HOSPITAL
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17B. ADDRESS OF HOSPITAL
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PATIENT/VETERAN'S SOCIAL SECURITY NO.
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17C. DIAGNOSIS Disease that results in physical and mental impairment described in questions 25 through 39)
Primary medical issue, often dementia, osteoarthritis, hypertension, type 2 diabetes
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18A. AGE
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ESTIMATED WEIGHT IN POUNDS (LBS)
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HEIGHT: FEET
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HEIGHT: INCHES
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19. NUTRITION
impaired appetite, decreased nutritionor put 'normal'
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20. GAIT: How they walk
unsteadyor uses rolling walker, uses wheelchair, normal
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21. BLOOD PRESSURE
approximate last blood pressure
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22. PULSE RATE
approximate last pulse
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23. RESPIRATORY RATE
approximate last respiratory rate
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24. WHAT DISABILITIES RESTRICT THE LISTED ACTIVITIES/FUNCTIONS?
generalized physical weakness, impaired mental cognitionBe sure to remove incorrect statements or put 'no restrictions'
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25. IF THE CLAIMANT IS CONFINED TO BED, INDICATE THE NUMBER OF HOURS IN BED FROM 9PM to 9AM
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25. IF THE CLAIMANT IS CONFINED TO BED, INDICATE THE NUMBER OF HOURS IN BED FROM 9AM to 9PM
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26. IS THE CLAIMANT ABLE TO FEED HIM/HERSELF?
YES
NO
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If no, explain:
cognitive decline impairs ability to feed self, physical weakness impairs ability to feed self, lacks coordination to feed selfBe sure to remove incorrect statements
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27. IS THE CLAIMANT ABLE TO PREPARE OWN MEALS?
YES
NO
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If no, explain:
cognitive decline impairs ability to prepare meals, physical weakness impairs ability to prepare meals, lacks coordination to prepare mealsBe sure to remove incorrect statements
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28. DOES THE CLAIMANT NEED ASSISTANCE IN BATHING AND TENDING TO OTHER HYGIENE NEEDS?
YES
NO
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If YES, explain:
cognitive decline impairs ability to bathe and tend to hygiene needs, physical weakness impairs ability to bathe and tend to hygiene needs, lacks coordination to bathe and tend to hygiene needsBe sure to remove incorrect statements
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29A. IS THE CLAIMANT LEGALLY BLIND? (needs report from eye doctor confirming 20/200 or less)
YES
NO
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If YES, explain:
include eye doctor last visit and vision test results
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CORRECTED VISION LEFT EYE
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CORRECTED VISION RIGHT EYE
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30. DOES THE CLAIMANT REQUIRE NURSING HOME CARE?
YES
NO
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If Yes, explain
Be sure to remove incorrect statements
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31. DOES THE CLAIMANT REQUIRE MEDICATION MANAGEMENT?
YES
NO
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If YES, explain
cognitive decline, physical weakness, lack of coordination impairs ability to manage medications Be sure to remove incorrect statements
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Can the Claimant have the mental capacity to manage benefit payments
YES
NO
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If NO, explain
cognitive decline impairs ability to manage benefit paymentsBe sure to remove incorrect statements
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PATIENT/VETERAN'S SOCIAL SECURITY NO.
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PATIENT/VETERAN'S SOCIAL SECURITY NO
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PATIENT/VETERAN'S SOCIAL SECURITY NO
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33. DESCRIBE POSTURE AND GENERAL APPEARANCE (Attach a separate sheet of paper if additional space is needed)
noted generalized weakness, unbalanced postureBe sure to remove incorrect statements, or put 'normal'
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34. DESCRIBE UPPER EXTREMITY IMPAIRMENT TO BUTTON CLOTHING, SHAVE AND ATTEND TO THE NEEDS OF NATURE (Attach a separate sheet of paper if additional space is needed)
Be sure to remove incorrect statements, or put 'No limitations' if normal
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35. DESCRIBE RESTRICTIONS OF EACH LOWER EXTREMITY WITH PARTICULAR REFERANCE TO THE EXTENT OF LIMITATION OF MOTION, ATROPHY, AND CONTRACTURES OR OTHER INTERFERENCE. IF INDICATED, COMMENT SPECIFICALLY ON WEIGHT BEARING, BALANCE AND PROPULSION OF EACH LOWER EXTREEMITY.
exhibits impaired gait, decreased range of motion, muscle disuse atrophy of left and right lower extremities.Be sure to remove incorrect statements, or put 'No limitations' if normal
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36. DESCRIBE RESTRICTION OF SPINE, TRUNK AND NECK
unbalanced posture, weakness of trunk musculature, forward-leaning neckBe sure to remove incorrect statements, or put 'No limitations' if normal
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37. SET FORTH ALL OTHER PATHOLOGY INCLUDING THE LOSS OF BOWEL OR BLADDER CONTROL OR THE EFFECTS OF ADVANCING AGE, SUCH AS DIZZINESS, LOSS OF MEMORY OR POOR BALANCE, THAT AFFECTS CLAIMANT'S ABILITY TO PERFORM SELF-CARE, AMBULATE OR TRAVEL BEYOND THE PREMISES OF THE HOME, OR, IF HOSPITALIZED, BEYOND THE WARD OR CLINICAL AREA. DESCRIBE WHERE THE CLAIMANT GOES AND WHAT HE OR SHE DOES DURING A TYPICAL DAY.
cognitive decline, physical weakness, lack of coordination contributes to inability to perform self-care, travel beyond the premises, urinary incontinence, bowel incontinenceBe sure to remove incorrect statements, or put 'No limitations' if normal
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38. DESCRIBE HOW OFTEN PER DAY OR WEEK AND UNDER WHAT CIRCUMSTANCES THE CLAIMANT IS ABLE TO LEAVE THE HOME OR IMMEDIATE PREMISES
cognitive decline, physical weakness, lack of coordination contributes to inability to regularly travel beyond the premises Be sure to remove incorrect statements, or put 'No limitations' if normal
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39. ARE AIDS SUCH AS CANES, BRACES, CRUTCHES, OR THE ASSISTANCE OF ANOTHER PERSON REQUIRED FOR LOCOMOTION? (If so, specify and describe effectiveness in terms of distance that can be traveled, as in Item 38 above)
YES
NO
1 BLOCK
5 OR 6 BLOCKS
1 MILE
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40A. PRINTED NAME OF PHYSICIAN
George Valdez
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40B. SIGNATURE AND TITLE OF EXAMINING PHYSICIAN (Do Not Sign)
Clear
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40C. DATE SIGNED (MM)
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40C. DATE SIGNED (DD)
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40C. DATE SIGNED (YYYY)
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41. NATIONAL PROVIDER IDENTIFIER (NPI) NUMBER
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42A. PHONE NUMBER OF MEDICAL FACILITY
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42B. NAME OF MEDICAL FACILITY
FHP Geriatrics
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42C. ADDRESS OF MEDICAL FACILITY
11007 Northpointe Blvd, Suite D, Tomball, TX 77375
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