Form VA Form 21P-8416 VA Form 21P-8416 Medical Expense Report

INSTRUCTIONS FOR MEDICAL EXPENSE REPORT
VA may be able to pay you a higher benefit rate if you identify expenses VA can deduct from your income. Your benefit
rate is based on your income. Your out-of-pocket payments for medical and dental expenses may be deductible.
Report any medical or dental expenses that you paid for yourself or for a relative who is a member of your household
(spouse, grandchild, parent, etc.) for which you were not reimbursed and do not expect to be reimbursed. Below are
examples of expenses you should include, if applicable:
•
•
•
•
•
•

Hospital expenses
Doctor's office fees
Dental fees
Prescription/non-prescription drug costs
Vision care costs
Medical insurance premiums

•
•
•
•

Nursing home costs
Hearing aid costs
Home health service expenses
Expenses related to transportation to a hospital,
doctor, or other medical facility
• Monthly Medicare deduction

IMPORTANT NOTES
• Do not include any expenses for which you were or will be reimbursed. If you receive reimbursement after you
have filed this claim, promptly notify the VA office handling your claim.
• If you are a veteran, VA can deduct allowable expenses paid by either you or your spouse.
• If you are not sure whether VA can deduct a payment for a particular expense, furnish a complete description of the
purpose of the payment. We will let you know if we cannot deduct an expense.
• If you are claiming expenses for an in-home care provider or for care in a facility other than a nursing home, you
must complete the appropriate worksheet to determine whether VA may deduct all or some of your payments to the
provider or facility and whether additional evidence is required. If the expenses are for your care, you are not in receipt
of special monthly benefits, and you want to make a claim, please attach a completed VA Form 21-2680, Examination
for Housebound Status or Permanent Need for Regular Aid and Attendance.
• VA may require you to verify the amounts you paid, so keep all receipts or other documentation of payments for
at least 3 years after we make a decision on your medical expense claim. If you are unable to provide documentation of
your claimed medical expenses when VA asks you to do so, your benefits may be retroactively reduced or discontinued.
• If you need more space to report expenses, attach a separate sheet of paper with columns corresponding to those on this
form. Be sure to write your VA file number on any attachments.
PRIVACY ACT NOTICE: VA will not disclose information collected on this form to any source other than what has been authorized under the
Privacy Act of 1974 or Title 38, code of Federal Regulations 1.576 for routine uses (i.e., civil or criminal law enforcement, congressional
communications, epidemiological or research studies, the collection of money owed to the United States, litigation in which the United States is a
party or has an interest, the administration of VA programs and delivery of VA benefits, verification of identity and status, and personnel
administration) as identified in the VA system of records, 58VA21/22/28, Compensation, Pension, Education, and Vocational Rehabilitation and
Employment Records - VA, published in the Federal Register. Your obligation to respond is required to obtain or retain benefits. The requested
information is considered relevant and necessary to determine maximum benefits provided under law. VA uses your SSN to identify your claim file.
Providing your SSN will help ensure that your records are properly associated with your claim file. Giving us your SSN account information is
voluntary. Refusal to provide your SSN by itself will not result in the denial of benefits. VA will not deny an individual benefits for refusing to
provide his or her SSN unless the disclosure of the SSN is required by a Federal Statute of law in effect prior to January 1, 1975, and still in effect.
The responses you submit are considered confidential (38 U.S.C. 5701). Information submitted is subject to verification through computer matching
programs with other agencies.
RESPONDENT BURDEN: We need this information to determine whether medical expenses you paid may be used to reduce the amount of
income we count in determining eligibility to benefits (38 U.S.C. 1503). Title 38, United States Code, allows us to ask for this information. We
estimate that you will need an average of 30 minutes to review the instructions, find the information, and complete this form. VA cannot conduct or
sponsor a collection of information unless a valid OMB control number is displayed. You are not required to respond to a collection of information if
this number is not displayed. Valid OMB control numbers can be located on the OMB Internet Page at www.reginfo.gov/public/do/PRAMain. If
desired, you can call 1-800-827-1000 to get information on where to send comments or suggestions about this form.
VA FORM
XXX XXXX

21P-8416

SUPERSEDES VA FORM 21P-8416, FEB 2012,
WHICH WILL NOT BE USED.

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OMB Control No. 2900-0161
Respondent Burden: 30 minutes
Expiration Date: XX/XX/XXXX
FOR VA USE ONLY

MEDICAL EXPENSE REPORT
1. FIRST NAME OF VETERAN

2. MIDDLE NAME OF VETERAN

3. LAST NAME OF VETERAN

6. VA FILE NUMBER

5. VETERAN'S SOCIAL SECURITY NO.
7. FIRST NAME OF CLAIMANT

4. SUFFIX NAME OF VETERAN

8. MIDDLE NAME OF CLAIMANT

9. LAST NAME OF CLAIMANT

10. SUFFIX NAME OF CLAIMANT
12. APT. NO.

11. STREET ADDRESS OF CLAIMANT
13. CITY

14. STATE

16. DAYTIME TELEPHONE NO. OF CLAIMANT (Include Area Code)

17. EVENING TELEPHONE NO. OF CLAIMANT (Include Area Code)

18. CHANGE OF ADDRESS (Check box if address in
Items 11-15 is different from last address furnished to VA)

15. ZIP CODE

19. E-MAIL ADDRESS OF CLAIMANT (If applicable)

20. MILEAGE FOR PRIVATELY OWNED VEHICLE TRAVEL FOR MEDICAL PURPOSES

Report miles traveled to a hospital, doctor, or other medical facility in a privately owned vehicle (POV) such as a car, truck, or motorcycle. Itemize travel occurring
between the dates ______________ and ________________. If no dates appear on this line, refer to the accompanying letter for the dates you should report medical
expenses. If you do not have a letter, please report unreimbursed medical expenses on a calendar year basis. We will calculate the allowable deduction for your mileage
based on the current POV mileage reimbursement rate for automobiles specified by the United States General Services Administration (GSA). You may locate the current
amount at www.gsa.gov or on VA's website at www.benefits.va.gov/pension.
NOTE: You may also claim deductions for other payments related to travel for medical purposes, such as taxi fares, buses, or other forms of public transportation. Report
these types of medical travel expenses in Item 22.
A. MEDICAL FACILITY TO WHICH
TRAVELED

B. TOTAL ROUNDTRIP
MILES TRAVELED

C. AMOUNT REIMBURSED
FROM ANOTHER SOURCE
(Such as a VA Medical Center)

D. DATE
TRAVELED

(Month/Day/Year)

E. WHO NEEDED TO
TRAVEL?
(Self, spouse, child)

IMPORTANT: Be sure to sign and date this form in Items 23A & 23B on page 4. Unsigned reports will be returned.
VA FORM
XXX XXXX

21P-8416

SUPERSEDES VA FORM 21P-8416, FEB 2012,
WHICH WILL NOT BE USED.

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21. IN-HOME ATTENDANT EXPENSES

IMPORTANT - You must complete the attached In-Home Attendant Worksheet (page 6) to claim in-home attendant expenses.
Report amounts paid between the dates __________________ and _________________. If no dates appear on this line refer to the accompanying letter for the dates you
should report medical expenses. If you do not have a letter, please report unreimbursed medical expenses on a calendar year basis.
A. NAME OF PROVIDER

B. HOURLY RATE/
NUMBER OF HOURS

D. DATE PAID
(Month/Day/Year)

C. AMOUNT PAID

E. FOR WHOM PAID
(Self, spouse, child, etc.)

22. ITEMIZATION OF MEDICAL EXPENSES
IMPORTANT - If you are claiming expenses for care in a facility that is not a nursing home, you must complete the appropriate worksheet (page 5).
Report medical expenses that you paid between the dates __________________ and _________________. If no dates appear on this line refer to the accompanying
letter for the dates you should report medical expenses. If you do not have a letter, please report unreimbursed medical expenses on a calendar year basis.
A. MEDICAL EXPENSE (Physician or
Hospital Charges, Eyeglasses, Oxygen
Rental, Medical Insurance, etc.)

B. AMOUNT PAID

C. DATE PAID
(Month/Day/Year)

D. NAME OF PROVIDER
(Name of doctor, dentist,
hospital, lab, etc.)

E. FOR WHOM PAID
(Self, spouse, child, etc.)

MEDICARE (PART B)
MEDICARE (PART D)
PRIVATE MEDICAL INSURANCE

VA FORM 21P-8416, XXX XXXX

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22. ITEMIZATION OF MEDICAL EXPENSES (Continued)
IMPORTANT - If you are claiming expenses for care in a facility that is not a nursing home, you must complete the appropriate worksheet (page 5).
Report medical expenses that you paid between the dates __________________ and _________________. If no dates appear on this line refer to the accompanying
letter for the dates you should report medical expenses. If you do not have a letter, please report unreimbursed medical expenses on a calendar year basis.
A. MEDICAL EXPENSE (Physician or
Hospital Charges, Eyeglasses, Oxygen
Rental, Medical Insurance, etc.)

B. AMOUNT PAID

C. DATE PAID
(Month/Day/Year)

D. NAME OF PROVIDER
(Name of doctor, dentist,
hospital, lab, etc.)

E. FOR WHOM PAID
(Self, spouse, child, etc.)

MEDICARE (PART B)
MEDICARE (PART D)
PRIVATE MEDICAL INSURANCE

CERTIFICATION: I have not and will not receive reimbursement for these expenses. I certify that the above information is true.
23A. SIGNATURE OF CLAIMANT (Do NOT print)

23B. DATE

PENALTY: The law provides severe penalties which include fine or imprisonment, or both, for the willful submission of any statement or evidence
of a material fact, knowing it is false, or fraudulent acceptance of any payment to which you are not entitled.
VA FORM 21P-8416, XXX XXXX

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WORKSHEET: EXPENSES FOR CARE IN A FACILITY OTHER THAN A NURSING HOME
IMPORTANT: VA recognizes the following six activities as Activities of Daily Living (ADLs) for medical expense purposes:
(1) Eating
(2) Bathing/Showering
(3) Dressing
(4) Transferring (for example, from bed to chair)
(5) Using the toilet
(6) Ambulating within the home or living area
Custodial Care is regular • supervision because a person with a physical, mental, developmental, or cognitive disorder requires care or assistance on a regular basis
to be protected from hazards or dangers incident to his or her daily environment, or
• assistance with two or more ADLs.
INSTRUCTIONS: Use this worksheet if you are claiming your or your relative's care in a facility other than a nursing home. Follow the steps below to determine what
expenses to claim and any additional evidence to provide. If you are not in receipt of special monthly benefits and wish to make a claim, please attach a completed
VA Form 21-2680, Examination for Housebound Status or Permanent Need for Regular Aid and Attendance with this report.

STEPS 1 THROUGH 6

NO

YES

STEP 1. Are the expenses you wish to claim due to your or your relative's treatment in a hospital,
inpatient treatment center, nursing home, or VA-approved medical foster home?
NOTE: If "YES," all payments to the facility qualify as medical expenses. You may claim them in Items 30A through 30F)

STEP 2. Do both of the following apply to the facility?
• The facility is licensed (if the State or country requires it)
• If the facility is residential, it is staffed 24 hours per day with care providers (the providers do not
have to be licensed).

(See "Note" then
stop)

(Continue)

(Continue)

(See "Note" then
stop)

(Continue)

(Continue)

(See "Note 1" then
continue)

(See "Note 2" then
stop)

NOTE: If "NO," payments to the facility do not qualify as medical expenses)

STEP 3. Are you the person who needs care?
STEP 4. Do you or your relative receive health care and/or custodial care in the facility?
NOTE 1: If "YES," you must attach a statement that (1) states you or your relative needs to be in a protected environment
because of a physical, mental, developmental, or cognitive disorder; and (2) describes the disorder. A physician;
physician assistant (PA); certified nurse practitioner (CNP), or clinical nurse specialist (CNS) may sign the statement.
NOTE 2: If "NO," you may only claim health care expenses provided by a licensed health care provider in Items 22A
through 22E.

STEP 5. Do you want to claim meals and lodging (and other facility expenses not directly related to
health care or custodial care)?

(See "Note 1"in
Step 4 then
continue)

(Continue)

STEP 6. Facility Certification: Please submit a current statement showing the fees the claimant pays to your facility and a breakdown of the
care received.

I CERTIFY that the information stated within this "Worksheet: Expenses for Care in a Facility Other than a Nursing Home" is accurate and
reflects the current and projected future environment pertaining to:
_______________________________________________________________________________________ and his or her care in this
(Name of Person Receiving Care in Facility)

facility_________________________________________________________________________________________________.
(Name and Address of Facility)

________________________________________________________________________________
(Name, Signature and Title of Person Certifying for the Facility)

VA FORM 21P-8416, XXX XXXX

____________________
(Date Certified)

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WORKSHEET: EXPENSES FOR IN-HOME ATTENDENT CARE
IMPORTANT: VA recognizes the following six activities as Activities of Daily Living (ADLs) for medical expense purposes:
(1) Eating
(2) Bathing/Showering
(3) Dressing
(4) Transferring (for example, from bed to chair)
(5) Using the toilet
(6) Ambulating within the home or living area
Custodial Care is regular • supervision because a person with a physical, mental, developmental, or cognitive disorder requires care or assistance on a regular basis
to be protected from hazards or dangers incident to his or her daily environment, or
• assistance with two or more ADLs.
IMPORTANT: For VA medical expense purposes, "health care providers" include persons who are • licensed by a state or country to provide health care. Examples: physicians, physician assistants, psychologists, chiropractors, clinical nurse specialists,
licensed practical nurses, and physical or occupational therapists, and
• nursing assistants or home health aides who are supervised by a licensed health care provider.
INSTRUCTIONS: Use this worksheet if you are claiming payments to your or your relative's in-home attendant as an unreimbursed medical expense.
You must complete a separate worksheet for each person whose care expenses you are claiming.
Follow the steps below to determine whether or not the in-home attendant must be a health care provider.

YES

STEPS 1 THROUGH 5
STEP 1. Are you the person who needs care?

NO

(Continue)

(Skip to
step 3)

(See "Note 1" then
skip to step 4)

(See "Note 2" then
continue)

STEP 2. Do you or your relative require custodial care?
NOTE 1: If "YES," you must attach a statement that (1) states you or your relative requires custodial care because
of a physical, mental, developmental, or cognitive disorder; and (2) describes the disorder. A physician;
physician assistant (PA); certified nurse practitioner (CNP), or clinical nurse specialist (CNS) may sign the statement.
NOTE 2: If "NO," the in-home attendant must be a health care provider.

STEP 3. Health Care Provider Certification (When Required):
I CERTIFY that I am a health care provider as defined above:
_______________________________________________________________________________________

(Date Certified)

(Name, Signature and Title of Health Care Provider or Supervisor)

STEP 4. Check all activities below with which the attendant assists the veteran or relative:
EATING

BATHING/SHOWERING

DRESSING

SHOPPING

FOOD PREPARATION

HOUSEKEEPING

USING THE TELEPHONE

USING THE
TOILET

TRANSFERRING

MANAGING
FINANCES

LAUNDERING

TRANSPORTATION FOR NON-MEDICAL PURPOSES

AMBULATING WITHIN THE
HOME OR LIVING AREA
HANDLING
MEDICATIONS

OTHER

STEP 5. In-Home Attendant Certification: Please submit a current breakdown of the time the attendant spends assisting the veteran or relative
with health care services, ADLs and other personal services.
I CERTIFY that the information stated within this "Worksheet For In-Home Attendant Expenses" is accurate and
reflects the current and projected future environment pertaining to_____________________________________________________________________
(Name of Person Requiring Care)

and his or her care from_________________________________________________________________________________________________.
(Name of Attendant)

__________________________________________________________________
(Name, Signature and Title of Attendant or Agency Certifying Official)

VA FORM 21P-8416, XXX XXXX

___________________
(Date Certified)

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