VA Form 10-1170: Long-Term Care Provider Application Guide – VA Form 10-1170 is a key document for healthcare providers, nursing homes, and community agencies seeking to partner with the U.S. Department of Veterans Affairs (VA) to deliver long-term care services to eligible veterans. This form helps the VA evaluate qualifications and establish contracts for community-based care, allowing veterans to receive services closer to home.
Download the official VA Form 10-1170 here:
Download VA Form 10-1170 (PDF)
What Is VA Form 10-1170?
VA Form 10-1170, titled “Application for Furnishing Long-Term Care Services to Beneficiaries of Veterans Affairs,” is an official VA document revised in November 2006. It is used by community providers (such as nursing homes, long-term care facilities, and related agencies) to apply for approval to provide services under VA contracts or agreements.
The form collects essential details about the provider, including facility information, licensing, certifications (e.g., Medicare/Medicaid), capacity, services offered, staffing (like director of nursing), safety features (e.g., fire sprinklers), and pricing/schedules for care levels. It supports VA’s Community Nursing Home Program and similar initiatives.
Note: This form is for providers and facilities, not individual veterans applying for personal long-term care benefits. Veterans typically work with VA social workers and use forms like 10-10EZ or 10-10EC.
Who Should Use VA Form 10-1170?
- Nursing homes and skilled nursing facilities
- Community long-term care providers
- Home health agencies (in some cases)
- Chains or organizations seeking VA contracts for veteran care
Providers use it to demonstrate they meet state licensing, quality, and safety standards so they can care for veterans through VA-funded programs. This expands access to care near veterans’ families and communities.
Why Is This Form Important for Long-Term Care Providers?
The VA contracts with community providers to supplement its own facilities (like VA Community Living Centers). Submitting Form 10-1170 is often a required step in becoming a VA-approved provider for long-term care, including nursing home placements for eligible veterans.
Benefits for providers include:
- Access to VA-referred veterans
- Potential steady revenue through contracts
- Opportunity to serve those who served our country
For veterans, it means more options for high-quality, localized long-term care without always needing VA-owned facilities.
Eligibility and Requirements for Providers
To qualify, providers must typically:
- Be licensed/approved by the state where located
- Be certified for Medicare/Medicaid participation (often required)
- Meet fire safety, staffing, and quality standards
- Provide details on capacity, services (case-mix/level of care), and pricing
- Have appropriate medical oversight (e.g., physician advisor, licensed director of nursing)
The VA reviews the application to ensure compliance with standards under Title 38 U.S.C. sections 1710 and 1730.
Submit supporting documents such as state licenses and certifications as requested.
How to Complete and Submit VA Form 10-1170?
- Download the fillable PDF from the official VA site.
- Fill in provider details: Name/address, Medicare number, licensing status, capacity, staffing, services schedule, etc.
- Attach any required additional sheets for schedules or comments.
- Sign the provider agreement section.
- Submit the required number of copies to the issuing VA office or medical center (contact your local VA facility for instructions).
The estimated burden is about 10 minutes, but gather all information in advance. Do not send to the OMB clearance address—use the specific VA contact.
Contact your nearest VA medical facility or use the VA Facility Locator for submission guidance and current processes.
VA Long-Term Care Options for Veterans
While providers use Form 10-1170, veterans access care through:
- VA Community Living Centers (VA-owned nursing homes)
- Community Nursing Homes (contracted facilities)
- Home and Community-Based Services
- State Veterans Homes
Eligibility depends on service-connected disability rating, income, clinical need, and availability. High-priority veterans (e.g., 70%+ service-connected) often have stronger access.
Veterans should contact a VA social worker or call 1-877-222-VETS (8387) for personalized help.
Common Questions About VA Form 10-1170
Is the form still current?
Yes, the November 2006 version remains the official form listed on va.gov.
Can individuals use it?
No. It is specifically for providers applying to furnish services.
What about Veterans Care Agreements (VCA)?
Newer processes may involve VA Form 10-10171 or direct contact with VA facilities. Form 10-1170 supports traditional contracting.
Where to get help?
Reach out to local VA medical centers or review resources on va.gov/geriatrics.
Supporting Veterans Through Quality Long-Term Care
VA Form 10-1170 plays a vital role in expanding high-quality long-term care options for America’s veterans. Providers who complete it accurately help ensure veterans receive dignified, accessible care in their communities.
For the most up-to-date information, always refer to official VA sources and consult with VA staff. Veterans and families: Start with enrollment in VA health care if needed. Providers: Prepare your documentation and connect with your local VA facility today.
This article is for informational purposes. Requirements and processes can change—verify directly with the VA.