Contents
Form Example
TEXASVETERANSCOMMISSION
TVC15b
ASSISTEDLIVINGSTATEMENT
EFF. 8/2000
Name of veteran must be provided whether statement is completed for veteranorforwidow.
NameofAssistedLivingFacility
Address
TelephoneNumber
LicenseNumber
RE:
NameofVeteran
Claim#orSSN
NameofClaimant
DateofAdmission
Claimant'sMailingAddress
City State Zip
STATEMENTOFCHARGES
AmountofRecurringGrossDailyChargesforAssistedLivingCare $
Amountpaidandnotreimbursed *$
CLAIMANTCERTIFICATION
*Icertifytheamountasidentifiedaboveisbeingpaidfrompersonalfunds. Theseexpensesarepaidoutofmypocketwithout reimbursementfromanysource. Irequestthisamountbeusedasacontinuingdeductionfrommycountableincome.
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SignatureofWitness** |
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SignatureofClaimant |
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**NOTE: Ifclaimantsignswithhis/hermark,themark |
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SignatureofWitness** |
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mustbewitnessedbytwowitnesses. |
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STATUSOFCLAIMANT: |
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Patientrequiresassistance? |
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oraresidence(needsdwelling)? |
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DisabilitiesRequiringassistance: |
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LevelofCare |
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ADDITIONALREMARKS: |
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IsClaimanteligibleforMedicare?
DateSigned |
SignatureofAssistedLiving |
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FacilityAdministratororAgent |
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Common mistakes
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Omitting the Veteran's Name: Many individuals forget to include the name of the veteran, regardless of whether the form is for the veteran themselves or a widow.
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Incorrect Facility Information: Providing inaccurate details about the assisted living facility, such as the address or license number, can delay processing.
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Missing Claimant Information: Failing to include the claimant's mailing address or other identifying information can lead to confusion and potential denial of the claim.
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Inaccurate Statement of Charges: It's crucial to ensure that the amount of recurring gross daily charges is correct. Mistakes here can affect the financial assessment.
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Certification Errors: Claimants often neglect to properly certify the payment amounts, which may result in claims being rejected.
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Signature Issues: Not having a witness sign when the claimant uses a mark instead of a signature can invalidate the form. This step is essential for proper documentation.
Key takeaways
Filling out the Texas Veterans Commission form can be straightforward if you keep a few key points in mind. Here are some important takeaways to consider:
- Complete the veteran's information: Always provide the name of the veteran, regardless of whether the statement is for the veteran or their widow.
- Include facility details: Make sure to fill in the name, address, telephone number, and license number of the assisted living facility.
- Provide accurate identification: Clearly state the name of the veteran, their claim number or Social Security Number, and the name of the claimant.
- Document financial information: Accurately list the amount of recurring gross daily charges for assisted living care and the amount paid that is not reimbursed.
- Certify the claim: The claimant must certify that the expenses are paid from personal funds without reimbursement from any source.
- Witness signatures: If the claimant signs with a mark, it must be witnessed by two individuals.
- Assess the claimant's needs: Indicate whether the claimant requires assistance or has specific disabilities that necessitate care.
- Check Medicare eligibility: Determine if the claimant is eligible for Medicare, as this may affect the claim.
- Signatures are crucial: Ensure that the form is signed by both the claimant and the administrator or agent of the assisted living facility.
By following these guidelines, you can ensure that the form is completed accurately and submitted correctly, helping to facilitate the process for the veteran or their family.
Steps to Using Texas Veterans Commission
Filling out the Texas Veterans Commission form requires careful attention to detail. This process involves providing specific information about the veteran or their widow, the assisted living facility, and the financial aspects of care. Once completed, this form can help ensure that the necessary deductions are accounted for in the veteran's financial assessments.
- Begin by entering the Name of the veteran at the top of the form. This is required regardless of whether the statement is for the veteran or their widow.
- Next, provide the Name of the Assisted Living Facility, followed by its Address, Telephone Number, and License Number.
- In the section labeled RE:, include the Name of Veteran, their Claim Number or SSN, and the Name of Claimant.
- Fill in the Date of Admission for the veteran in the assisted living facility.
- Enter the Claimant's Mailing Address, including City, State, and Zip Code.
- In the STATEMENT OF CHARGES section, indicate the Amount of Recurring Gross Daily Charges for Assisted Living Care and the Amount paid and not reimbursed.
- Complete the CLAIMANT CERTIFICATION section by confirming that the amount listed is being paid from personal funds. Check the box indicating that these expenses are out-of-pocket without reimbursement.
- Sign the form in the Signature of Claimant section. If the claimant uses a mark, ensure it is witnessed by two individuals.
- Indicate the Status of Claimant by answering whether the patient requires assistance or has a residence that needs dwelling.
- List any Disabilities Requiring Assistance and specify the Level of Care needed.
- Provide any Additional Remarks if necessary, including whether the claimant is eligible for Medicare.
- Finally, sign and date the form in the Signature of Assisted Living Facility Administrator or Agent section.