Fillable Form VA 10-2409

VA 10-2409 Form acts as an agreement with hospital in relation to a home other than his/her own. It is included here the amount the patient agrees to pay in exchange for room, board, laundry and attention to his/her welfare

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What is Form VA 10-2409?


Form VA 10-2409, Patient’s Agreement with Hospital in Relation to a Home Other Than His Own, is used by a veteran, payee, and a social worker to create a legal agreement with a certain hospital in relation to the veteran’s home. 


 


Veterans may be able to receive the following benefits through this VA 10 2409 Form:


  • Nursing and medical care from medical professionals all throughout the day for the whole week

  • Professional physical therapy 

  • Help with daily tasks such as bathing, dressing, making meals, and taking necessary medicine at proper times

  • Comfort care and help with managing different kinds of physical pain

  • Support for the caregivers of certain veterans who may need professional help or a break so that they can work, travel, or run necessary errands

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    The homes of certain veterans may vary. Veterans may be able to get the assisted living benefits stated above in many different settings. These settings may be run by certain Veteran Affairs (VA) stations and other settings are currently being run by state or community organizations that the United States Department of Veteran Affairs (US DVA) inspects before approval. The types of homes a veteran can reside in include, but are not limited to the following:


  • Nursing homes

  • Assisted living centers

  • Private homes where a nurse or a caregiver supports and helps a small group of individuals or veterans

  • Adult day health and care centers

  • Veterans’ own homes

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    In each of the listed assisted living settings, the veteran can live there full time and have access to nursing and medical care. He or she may be able to get Veteran Affairs (VA) benefits to help pay for nursing home care. It depends on the veteran’s income and the level of his or her service-connected disability.


     


    A veteran may be able to receive any of these services if he or she meets all of the requirements listed below:


  • The veteran has finished signing up for health care from the United States Department of Veteran Affairs (US DVA)

  • The United States Department of Veteran Affairs (US DVA) has concluded that the veteran is in need of a specific service to help with his or her ongoing medical treatment and personal care for a certain illness, chronic disease, and other similar problems

  • The service or space in that particular care setting is available near the veteran

    •  


    The United States Department of Veteran Affairs (US DVA) may also consider other factors such as the service-connected disability status or insurance coverage of the veteran. Furthermore, the United States Department of Veteran Affairs (US DVA) also covers a number of these services under the veteran’s standard health benefits if he or she signed up for Veteran Affairs (VA) health care. 


     


    The veteran may still need to pay a copay for other covered services since these services are not covered under Veteran Affairs (VA) health care benefits. For these services, the veteran may be able to pay through Medicaid, Medicare, or his or her own private insurance.


     


    A complete VA 10 2409 Form must contain the following information:


  • The name of the Veteran Affairs (VA) station where the payee, veteran, and social worker went to

  • The residential or home address of the veteran

  • The telephone number of the veteran

  • The full legal name of the veteran

  • The social security number of the veteran

  • The Veteran Affairs (VA) claim number for this VA 10 2409 Form

  • The amount that the veteran has agreed to pay the payee for his or her room, board, laundry, and attention to his or her welfare

  • The full legal name of the payee

  • The residential or home address of the payee

  • The telephone number of the payee

  • The full legal name of the social worker who will serve as a witness for the signing of this VA 10 2409 Form

  • The details of this agreement

  • The signature of the veteran

  • The signature of the social worker who will serve as a witness

  • The current date of signing

    • How to fill out Form VA 10-2409?


    Taxpayers can download and print a PDF copy of the VA Form 10 2409 from the United States Department of Veteran Affairs (US DVA) website that they can manually complete. They can also fill out VA Form 10 2409 electronically on PDFQuick.


     


    To fill out the VA Form 10 2409, you must provide the following information:


     


    Item 1. Name of Veteran Affairs (VA) Station


    Enter the name of the Veteran Affairs (VA) Station you, the veteran, and the social worker went to.


     


    Item 2. Address


    Enter the residential or home address of the veteran.


     


    Item 3. Telephone number


    Enter the telephone number of the veteran.


     


    Item 4. Name of Veteran


    Enter the full legal name of the veteran.


     


    Item 5. Social Security Number (SSN)


    Enter the social security number (SSN) of the veteran.


     


    Item 6. Claim Number


    Enter the claim number for this VA 10 2409 Form.


     


    Item 7. Agree to Pay Monthly


    Enter the amount you have agreed to pay monthly for the veteran.


     


    Item 8. Name of Payee


    Enter your full legal name.


     


    Item 9. Address


    Enter your residential or home address.


     


    Item 10. Telephone


    Enter your telephone number.


     


    Item 11. Name of Social Worker


    Enter the full legal name of the social worker who will serve as the witness of the signing of this VA 10 2409 Form.


    Agreement


    By signing this VA 10 2409 Form, the veteran must agree to pay the amount that has been specified in item number 7 to you monthly for room, board, laundry, and attention to his or her overall welfare. Furthermore, the veteran must agree to discuss with you any matter of concern that may arise during the course of this agreement with the social worker before he or she can make any changes in the said agreement.


     


    Item 12. Signature of Veteran


    Have the veteran affix his or her signature.


     


    Item 13. Date


    Enter the current date of signing.


     


    Item 14. Signature of Social Worker or Witness


    Have the social worker serving as the witness affix his or her signature.


     


    Item 15. Date


    Enter the current date of signing.




    Table of Contents
    Fillable Form VA 10-2409