Checklist For Information to be Returned with Application
- Yukio Okutsu State Veterans Home Inquiry & Admission Application
- The following forms: VA Form 10-10EZ Application for Health Benefits
- “Discharge Papers” WD Form 53/54, DD Form 214 or Statement of Service (mandatory) You can obtain a copy of your “Discharge Papers” from the National Records Archives either on line Using the eVetRecs system, or print out a copy of SF Form 180
- Proof of Residence or voter’s records, employment records, State income tax records, etc. (if questionable)
- Copy of legal Power of Attorney (if appropriate)
- Signed Copy of Authorization for Disclosure of Health Information
- If applicant is in a long term care facility, please include the following items when returning admission packet:
- Nurse's Notes (last 3 months)
- Physician Notes (last 3 months)
- Social Services Notes MDS & Care Plan
- History & Physical (must be completed no earlier than 5 days prior to admission)
- If applicant is in the hospital during the application process, please include the following when returning the admission packet: History & Physical, Medical Summary, Discharge Summary will be required at admission
- The Admissions Coordinator may request additional documents; your quick responses to those requests are very much appreciated.
If filing claim for Non Service Connected Pension with Aid & Attendance send proof of income,
marital documents, and need of medical evidence showing disability is permanent and total,
DD-214 or equivalent.
For either claim filed, an appointment of a Veterans Service Organization VA 21-22, or an appointment of an individual as laimants' representative VA 21-22a should accompany the claim.
Failure to provide the requested information could adversely affect your prospects for entering Yukio Okutsu State Veterans Home - Hilo. Each form serves a specific purpose, whether it is for the Admissions Committee to determine your medical eligibility for admission or the category of skilled care you will require or for the expediting of the processing for payment of the VA Per Diem to the Home. In any case, these documents are of the utmost importance and merit your closest attention. Acceptance for Admission or placement on the waiting list will not occur until all information is received.