VA Form 21-2680 Examination for Housebound Status or Permanent Need for

OMB Control No. 2900-0721
Respondent Burden: 30 minutes
Expiration Date: XX/XX/XXXX

VA DATE STAMP

(DO NOT WRITE IN THIS SPACE)

EXAMINATION FOR HOUSEBOUND STATUS OR PERMANENT NEED
FOR REGULAR AID AND ATTENDANCE
INSTRUCTIONS: Before completing this form, read the Privacy Act and Respondent Burden on page
4. Use this form to determine eligibility for aid and attendance or housebound benefits. For more
information, you can contact us online through Ask VA: https://ask.va.gov/. Ask us a question online
or call us toll-free at 1-800-827-1000 (TTY: 711). VA forms are available at www.va.gov/vaforms.
SECTION I: VETERAN'S IDENTIFICATION INFORMATION
NOTE: You may complete the form online or by hand. If completing by hand, print neatly and legibly in ink, and completely fill in each applicable check box to
help expedite processing of the form.
1. VETERAN/BENEFICARY NAME (First, Middle Initial, Last)

2. SOCIAL SECURITY NUMBER

3. VA FILE NUMBER (If applicable)

4. VETERAN'S SERVICE NUMBER (If applicable)

5. DATE OF BIRTH (MM/DD/YYYY)

SECTION II: CLAIMAINT'S IDENTIFICATION INFORMATION
6. CLAIMANT'S NAME (First, Middle Initial, Last)

8. RELATIONSHIP OF CLAIMANT TO VETERAN

7. CLAIMANT'S SOCIAL SECURITY NUMBER

SELF

PARENT

SPOUSE

CHILD

9. CLAIMANT'S DATE OF BIRTH (MM/DD/YYYY)

10. MAILING ADDRESS (Number and street or rural route, P. O. Box, City, State, ZIP Code and Country)
No. &
Street
Apt./Unit Number
State/Province

City
Country

ZIP Code/Postal Code

11. TELEPHONE NUMBER (Optional) (Include Area Code)
Enter International Phone Number (If applicable)
12. EMAIL ADDRESS (Optional)

I agree to receive electronic correspondence from VA in regards to my claim.

SECTION III: CLAIM INFORMATION
13. SELECT ONE OF THE FOLLOWING BENEFITS (Choose one)

Special Monthly Compensation (SMC) - Veterans and surviving spouses or parents who are eligible to receive VA compensation due to a service-related disability
or death and require aid and attendance of another person to perform personal functions required in everyday living such as bathing, feeding, dressing, attending to
the wants of nature, adjusting prosthetic devices, or protecting oneself from the hazards of the daily environment may be eligible for Special Monthly Compensation.
A veteran or a deceased veteran's surviving spouse may also be eligible for Special Monthly Compensation based on being housebound (substantially confined to the
immediate premises because of permanent disability). For a veteran, the disability causing the need for aid and attendance or housebound status must be related to
service. These benefits are paid in addition to monthly compensation or Dependency Indemnity Compensation (DIC). They are not paid without eligibility to
compensation.
Special Monthly Pension (SMP) - Veterans and survivors who are eligible for Veteran's Pension and/or Survivors benefits and require the aid and attendance of
another person in order to perform personal functions required in everyday living, such as bathing, feeding, dressing, attending to the wants of nature, adjusting
prosthetic devices, or protecting them from the hazards of their daily environment, or are housebound (substantially confined to their immediate premises because of
permanent disability), may be eligible for Special Monthly Pension (SMP). This benefit is an increased monthly amount paid to a veteran or survivor who is
eligible for Veterans Pension or Survivors benefits.
VA FORM
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21-2680

SUPERSEDES VA FORM 21-2680, SEP 2018.

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VETERAN'S SOCIAL SECURITY NUMBER

SECTION IV: IS VETERAN/CLAIMANT HOSPITALIZED?
14B. DATE ADMITTED (MM/DD/YYYY)

14A. IS THE CLAIMANT HOSPITALIZED?
YES (If "YES," complete Items 14B, 14C & 14D)
NO (If "NO," skip to Section V)
14C. NAME OF HOSPITAL

14D. ADDRESS OF HOSPITAL

SECTION V: CERTIFICATION AND SIGNATURE
I CERTIFY THAT the statements on this form are true and correct to the best of my knowledge and belief.
15A. VETERAN/CLAIMANT/AUTHORIZED SIGNER'S SIGNATURE

15B. DATE SIGNED (MM/DD/YYYY)

SECTION VI: EXAMINATION INFORMATION
(IMPORTANT: Remainder of form MUST be filled out by Examiner)
NOTE: The Examiner must be a Medical Doctor (MD) or Doctor of Osteopathic (DO) medicine.
16. DATE OF EXAMINATION (MM/DD/YYYY)

NOTE: EXAMINER PLEASE READ CAREFULLY
The purpose of this examination is to record manifestations and findings pertinent to the question of whether the veteran/claimant is
housebound (confined to the home or immediate premises) or in need of the regular aid and attendance of another person. Please provide
as much description as needed for each question as this will assist VA to determine if the disease(s) or injury(ies) listed may lead to
physical or mental impairment, loss of coordination or enfeeblement that require assistance with daily living. Findings should be recorded to
show whether the claimant is blind or bedridden. Whether the claimant seeks housebound or aid and attendance benefits, the report should
reflect how well they ambulate, where they go, and what they are able to do during a typical day.
17. PROVIDE COMPLETE DIAGNOSIS WITH MOST SIGNIFICANT SYMPTOMS FOR EACH CONDITION (Diagnosis needs to equate to the level of assistance described
in Items 26 through 37) (Describe below)

18. WHAT DISABILITY(IES) ARE CONSIDERED PERMANENT AND TOTALLY DISABLING? (Describe below)
A.

D.

B.

E.

C.

F.

19A. AGE

19C. HEIGHT

19B. WEIGHT
ACTUAL LBS.

ESTIMATED LBS.

20. NUTRITION

22. BLOOD PRESSURE

FEET

INCHES
21. GAIT

23. PULSE RATE

VA FORM 21-2680, XXX XXXX

24. RESPIRATORY RATE

25. WHAT DISABILITIES RESTRICT THE LISTED ACTIVITIES/FUNCTIONS?

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VETERAN'S SOCIAL SECURITY NUMBER
26. IF THE PATIENT IS CONFINED TO BED, INDICATE THE NUMBER OF HOURS IN BED
From 9 PM to 9 AM:

From 9 AM to 9 PM:

27. DOES THE PATIENT REQUIRE ASSISTANCE WITH ANY OF THE FOLLOWING ACTIVITIES? (Select ALL that apply)
BATHING/SHOWERING

TENDING TO HYGIENE NEEDS

FEEDING AND MEAL PREPARATION

TRANSFERRING IN OR OUT OF BED/CHAIR

DRESSING

TOILETING

AMBULATING WITHIN THE HOME
OR LIVING AREA

MEDICATION MANAGEMENT

ADDITIONAL ACTIVITIES (i.e., housekeeping, laundering,
managing finances, etc.) (Specify additional activity below)

28B. CORRECTED VISION

28A. IS THE PATIENT LEGALLY BLIND? (If "Yes," provide explanation)
YES

LEFT EYE

RIGHT EYE

NO
29. DOES THE PATIENT REQUIRE NURSING HOME CARE? (If "Yes," provide explanation)
YES
NO
30. IN YOUR JUDGMENT, DOES THE PATIENT HAVE THE MENTAL CAPACITY TO MANAGE THEIR BENEFIT PAYMENTS, OR ARE THEY ABLE TO
DIRECT SOMEONE TO DO SO?
YES
NO
(If "NO," provide the
disability(ies) that prevent
them from performing this
function and any rationale
to support your
conclusion in the space
provided)
31. WHAT IS THE POSTURE AND GENERAL APPEARANCE OF THE PATIENT? (Describe)

32. DESCRIBE RESTRICTIONS OF EACH UPPER EXTREMITY WITH PARTICULAR REFERANCE TO GRIP, FINE MOVEMENTS, AND ABILITY TO FEED THEMSELVES,
TO BUTTON CLOTHING, SHAVE AND ATTEND TO THE NEEDS OF NATURE

33. DESCRIBE RESTRICTIONS OF EACH LOWER EXTREMITY WITH PARTICULAR REFERANCE TO THE EXTENT OF LIMITATION OF MOTION, ATROPHY, AND
CONTRACTURES OR OTHER INTERFERENCE. (NOTE: If indicated, comment specifically on weight bearing, balance and propulsion of each lower extremity)

34. DESCRIBE RESTRICTION OF SPINE, TRUNK, AND NECK

VA FORM 21-2680, XXX XXXX

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VETERAN'S SOCIAL SECURITY NUMBER
35. DESCRIBE ALL OTHER PATHOLOGY INCLUDING THE LOSS OF BOWEL OR BLADDER CONTROL OR THE EFFECTS OF ADVANCING AGE; SUCH AS DIZZINESS,
LOSS OF MEMORY OR POOR BALANCE, THAT AFFECTS PATIENT'S ABILITY TO PERFORM SELF-CARE, OR IF HOSPITALIZED, BEYOND THE WARD OR CLINICAL
AREA

36. HOW OFTEN PER DAY OR WEEK AND UNDER WHAT CIRCUMSTANCES (to include the level of assistance required) IS THE PATIENT ABLE TO LEAVE THE HOME OR
IMMEDIATE PREMISES (Describe)

37. ARE AIDS SUCH AS CANES, BRACES, CRUTCHES, OR THE ASSISTANCE OF ANOTHER PERSON REQUIRED FOR LOCOMOTION?
YES (If "YES," check the applicable
box or specify distance)

1 BLOCK

5 OR 6 BLOCKS

1 MILE

NO

OTHER
(Specify distance)________________________

SECTION VII: EXAMINER'S SIGNATURE
38. PRINTED NAME OF EXAMINER

39. TITLE OF EXAMINER

40. SIGNATURE AND TITLE OF EXAMINER (REQUIRED)

41. DATE SIGNED (MM/DD/YYYY)

SECTION VIII: EXAMINER'S INFORMATION
42. NATIONAL PROVIDER IDENTIFIER (NPI) NUMBER OF EXAMINER

43. NAME OF MEDICAL FACILITY

44. ADDESS OF MEDICAL FACILITY (Number and street or rural route, city, state, ZIP Code and Country)

45. TELEPHONE NUMBER OF MEDICAL FACILITY (Include Area Code)
Enter International Phone Number (If applicable)
PENALTY: The law provides severe penalties (including fine and/or imprisonment) for willfully submitting any statement or evidence of a material fact you know to be false, or for
fraudulent receipt of any document you are not entitled to.
PRIVACY ACT NOTICE: The 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 Veteran Readiness and Employment Records - VA, published in the Federal
Register. Your obligation to respond is required to obtain or retain benefits. Giving us your Social Security Number (SSN) account information is mandatory. Applicants are required to provide
their SSN under Title 38, U.S.C. 5701(c)(1). The VA will not deny an individual benefits for refusing to provide his or her SSN unless the disclosure is required by a Federal Statute of law in
effect prior to January 1, 1975, and still in effect. The requested information is considered relevant and necessary to determine maximum benefits provided under the law. The responses you submit
are considered confidential (38 U.S.C. 5701). Information that you furnish may be utilized in computer matching programs with other Federal or state agencies for the purpose of determining your
eligibility to receive VA benefits, as well as to collect any amount owed to the United States by virtue of your participation in any benefit program administered by the Department of Veterans
Affairs.
RESPONDENT BURDEN: We need this information to determine your eligibility for aid and attendance or housebound benefits. Title 38, United States Code 1521 (d) and (e), 1115(1)(e),
1311(c) and (d), 1315(h), 1122, 1541(d)(e), and 1502 (b) and (c) 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 website at http://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 21-2680, XXX XXXX

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