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 assisted living or similar care, you must complete the
appropriate worksheet to determine whether VA may deduct all or some of your payments to the provider or facility.
• 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 2014

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 (ex. 01/01/XXXX thru 12/31/XXXX). 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).
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 2014

21P-8416

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

Page 2

21. IN-HOME ATTENDANT EXPENSES

IMPORTANT - You must complete the attached In-Home Attendant Worksheet (page 5) 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 (ex. 01/01/XXXX thru 12/31/XXXX).
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 an assisted living, adult day care, or a similar facility, you must complete the appropriate worksheet (page 6).
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
(ex. 01/01/XXXX thru 12/31/XXXX).
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 2014

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22. ITEMIZATION OF MEDICAL EXPENSES (Continued)
IMPORTANT - If you are claiming expenses for care in an assisted living, adult day care, or a similar facility, you must complete the appropriate worksheet (page 6).
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
(ex. 01/01/XXXX thru 12/31/XXXX).
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 2014

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WORKSHEET FOR IN-HOME ATTENDANT EXPENSES
NOTE: Only complete this worksheet if you are claiming expenses for in-home care.
IMPORTANT: VA recognizes the following five 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
Custodial Care is regular • assistance with two or more ADLs, or
• supervision because a person with a mental disorder is unsafe if left alone due to the mental disorder
IMPORTANT: The following activities are examples of Instrumental Activities of Daily Living (IADLs) for VA purposes. VA generally does not recognize
assistance
with these activities as medical expenses: (1) Shopping; (2) Food Preparation; (3) Housekeeping; (4) Laundering; (5) Handling medications; (6) Using the
telephone;
(7) Transportation (except for medical purposes such as transportation to a doctor's appointment).
INSTRUCTIONS: Use this worksheet if you are claiming payments to a disabled person's in-home attendant as an unreimbursed medical expense.
Follow the steps below to determine whether or not:
• the attendant must be a health care provider for VA purposes and
• VA may deduct payment for assistance with IADLs as well as assistance with ADLs and custodial care
STEP 1. Are you (the claimant) the disabled person?
YES

NO

(If "NO," skip to Step 6)

STEP 2. Has VA determined that you are eligible for special monthly pension? (Special monthly pension means pension at the aid and attendance
or housebound rate or Parents' DIC at the aid and attendance level)
YES

NO

(If "YES," the attendant does not need to be a health care provider. Skip to Step 3)
(If "NO," skip to Step 4)

STEP 3. Is the primary responsibility of the in-home attendant to provide you with health care services or custodial care?
YES

NO

(If "YES," payments to this in-home attendant qualify as medical expenses (even if the attendant also assists you with IADLs). You
may claim these expenses in Item 21. Skip to Step 8)
(If "NO," payments to this in-home attendant for assistance with IADLs do not qualify as medical expenses. Payments for health care
services and custodial care qualify as medical expenses. You may claim these expenses in Item 21. Skip to Step 8)

STEP 4. Are you claiming special monthly pension?
YES

NO

(If "YES," please complete and attach with this application VA Form 21-2680, Examination for Housebound Status or Permanent Need for
Regular Aid and Attendance. Please make sure every item on this form is complete and signed by a Physician, Physician Assistant (PA),
Certified Nurse Practitioner (CNP), or Clinical Nurse Specialist (CNS))
(If "NO," the attendant must be a health care provider and payments for assistance with IADLs do not qualify as medical expenses.
Payments for health care services or assistance with ADLs qualify as medical expenses. You may claim these expenses in Item 21. Skip
to Step 8)

STEP 5. Is the primary responsibility of the in-home attendant to provide you with health care or custodial care?
YES

NO

(If "YES," payments to this in-home attendant may qualify as medical expenses if VA rates you as eligible for special monthly pension.
Please report separately in Item 21 amounts you pay an in-home attendant for: (1) health care services or assistance with ADLs provided
by a health care provider, (2) assistance with IADLs; and (3) custodial care. Skip to Step 8)
(If "NO," payments to this in-home attendant for assistance with IADLs do not qualify as medical expenses. Please report separately in
Item 21 applicable amounts you pay an in-home attendant for: (1) health care services or assistance with ADLs provided by a health care
provider, and (2) custodial care. Skip to Step 8)

STEP 6. Does the disabled person require the health care services or custodial care that the in-home attendant provides to him or her because of the
disabled person's mental or physical disability?
YES

NO

(If "YES," you must submit a statement from a physician or physician assistant that: (1) the disabled person requires the health care
services or custodial care that the attendant provides him or her because of mental or physical disability, and (2) describes the mental or
physical disability. The in-home attendant does not need to be a health care provider)
(If "NO," the attendant must be a health care provider and payments for assistance with IADLs do not qualify as medical expenses.
Payments to the in-home attendant for health care services or assistance with ADLs provided by a health care provider qualify as medical
expenses.. You may claim these expenses in Item 21. Skip to Step 8)

STEP 7. Is the primary responsibility of the in-home attendant to provide the disabled person with health care and/or custodial care?
YES

NO

(If "YES," payments to the in-home attendant qualify as medical expenses (even if the attendant also assists the disabled person with
IADLs. You may claim these expenses in Item 21)
(If "NO," payments to the in-home attendant for assistance with IADLs do not qualify as medical expenses. Payments to the in-home
attendant for health care or custodial care qualify as medical expenses. You may report these expenses in Item 21)

STEP 8. Check all activities below that the attendant assists the disabled person with:
ADLs:

EATING

BATHING/SHOWERING

HOUSEKEEPING

IADLs:

USING THE TELEPHONE

DRESSING

LAUNDERING

TRANSFERRING

MANAGING FINANCES

USING THE TOILET

SHOPPING

FOOD PREPARATION

HANDLING MEDICATIONS

TRANSPORTANTION FOR NON-MEDICAL PURPOSES

STEP 9. In-Home Attendant Certification: Please submit a current breakdown of the time the attendant spends assisting the disabled person with
health care services, ADLs and IADLs.
I CERTIFY that the information stated within this WORKSHEET FOR IN-HOME ATTENDANT EXPENSES is accurate and
reflects the current environment pertaining to _______________________________________________________________________________________ and his or her care
(Name of Person Requiring Care)
from_________________________________________________________________________________________________.
(Name of Attendant)
(Name, Signature and Title of Certifying Official)

(Date Certified)

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WORKSHEET FOR AN ASSISTED LIVING, ADULT DAY CARE, OR A SIMILAR FACILITY
NOTE: Only complete this worksheet if you are claiming expenses for an assisted living facility, adult day care or similar facility.
IMPORTANT: VA recognizes the following five 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
Custodial Care is regular • assistance with two or more ADLs, or
• supervision because a person with a mental disorder is unsafe if left alone due to the mental disorder.
INSTRUCTIONS: Use this worksheet if you are claiming a disabled person's care in an assisted living facility, adult day care, or similar facility as unreimbursed
medical expenses. Follow the steps below to determine whether VA may deduct all or some of your out-of-pocket payments to the facility.

STEP 1. Are the expenses you wish to claim due to the disabled person's treatment in a hospital, inpatient treatment center, nursing home, or VA approved
medical foster home?
YES

NO

(If "NO," continue to Step 2)

(If "YES," all payments to the facility qualify as medical expenses. You may claim these expenses in Item 22.
You are finished completing this worksheet)

STEP 2. Do all of the following apply to the facility?
• The facility is licensed (if the State or country requires it)
• The facility's staff (or the facility's contracted staff) provides the disabled person with
health care or custodial care or both.
• If the facility is residential, it is staffed 24 hours per day with caregivers
YES

NO

(If "NO," payments to the facility do not qualify as medical expenses. You are finished completing this worksheet)

STEP 3. Are you (the claimant) the disabled person? Are you a veteran, surviving spouse, or Parents' DIC claimant?
YES

NO

(If "NO," to either of these questions, skip to Step 8)

STEP 4. Has VA determined that you are eligible for special monthly pension? (Special monthly pension means pension at the aid and attendance or
housebound rate or Parents' DIC at the aid and attendance level)
YES

NO

(If "NO," skip to Step 6)

STEP 5. If you answered "YES" in Step 2, you stated that the facility provides you with health care and/or custodial care.
Is this the primary reason you live in the facility (or attend day care in the facility)?
YES

NO

(If "YES," all payments to this facility qualify as medical expenses. You may claim these expenses in Item 22. Skip to Step 10)
(If "NO," payments to this facility for meals and lodging do not qualify as medical expenses. Only claim amounts you pay the facility for
health care services or custodial care)

STEP 6. Are you claiming special monthly pension?
YES

NO

(If "YES," please complete and attach with this application VA Form 21-2680, Examination for Housebound Status or Permanent Need
for Regular Aid and Attendance. Please make sure every item is complete and the form is signed by a Physician, Physician Assistant (PA),
Certified Nurse Practitioner (CNP), or Clinical Nurse Specialist (CNS))
(If "NO," payments to this facility for meals and lodging do not qualify as medical expenses. Only claim amounts you pay the facility for
health care services or assistance with ADLs provided by a health care provider in Item 22. Skip to Step 10)

STEP 7. If you answered "YES" in Step 2, you stated that the facility provides you with health care and/or custodial care.
Is this the primary reason you live in the facility (or attend day care in the facility)?
YES

NO

(If "YES," all payments to this facility may qualify as medical expenses if VA rates you as eligible for special monthly pension or Parents'
DIC. Please report separately in Item 22 applicable amounts you pay the facility for: (1) lodging and meals, (2) health care services or
assistance with ADLs provided by a health care provider, and (3) custodial care. Skip to Step 10)
(If "NO," payments to this facility for meals and lodging do not qualify as medical expenses. Please report separately in Item 22
applicable amounts you pay the facility for: (1) health care services or assistance with ADLs provided by a health care provider,
and (2) custodial care. Skip to Step 10)

STEP 8. Does the disabled person require the health care services or custodial care that the facility provides to him or her because of the disabled person's
mental or physical disability?
YES

NO

(If "YES," you must submit a statement from a physician or physician assistant that: (1) the disabled person requires the health care
services or custodial care that the facility provides to him or her because of mental or physical disability, and (2) describes the mental or
physical disability)
(If "NO," claim only amounts you pay the facility for health care services or assistance with ADLs provided by a health care provider in
Item 22. Skip to Step 10)

STEP 9. If you answered "YES" in Step 2, you stated that the facility provides the disabled person with health care and/or custodial care. Is this the primary
reason the disabled person lives in the facility or attends day care in the facility?
YES

NO

(If "YES," claim all payments to this facility (to include meals and lodging) as medical expenses in Item 22)
(If "NO," payments to this facility for meals and lodging do not qualify as medical expenses. Only claim amounts you pay the facility for
health care services or custodial care in Item 22)

STEP 10. 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 FOR AN ASSISTED LIVING, ADULT DAY CARE, OR SIMILAR FACILITY is accurate and reflects the current
environment pertaining to _______________________________________________________________________________________ and his or her care at this
(Name of person staying at your facility)

facility_____________________________________________________________________.
(Name and address of facility)
(Name, Signature and Title of Person Certifying for the Facility)

(Date Certified)

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