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 report medical expenses for VA to deduct from your income. Your
benefit rate is calculated based on your income. Your out-of-pocket payments for medical, optical and dental expenses may
be deductible.
This form is used to report any medical expenses that you paid for yourself or for a relative who is a dependent member of
your household (spouse, child, grandchild, parent, etc.), for which you were not reimbursed and do not expect to be
reimbursed. Below are examples of expenses you may 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

THE FORM IS COMPRISED OF 8 SECTIONS.
BE SURE TO ANSWER THE QUESTION(S) IN EACH SECTION AS REQUIRED.
SECTION I: VETERAN'S IDENTIFICATION INFORMATION
SECTION II: CLAIMANT'S CONTACT INFORMATION
SECTION III: REPORTING PERIOD
SECTION IV: IN-HOME CARE AND CARE FACILITY EXPENSES

SECTION V: OTHER MEDICAL EXPENSES
SECTION VI: MILEAGE
SECTION VII: CERTIFICATION AND SIGNATURE
SECTION VIII: WITNESS TO SIGNATURE

This form contains the following addendums and worksheets that may be required to support your application:
Addendum:
• A: In-Home Care or Care Facility Expenses
• B: Other Medical Expenses Continued
• C: Mileage Traveled for Medical Purposes Using
Privately Owned Vehicle

Worksheet:
• Residential Care, Adult Daycare, or a Similar Facility
• In-Home Attendant Expenses

IMPORTANT INFORMATION
• All medical expenses must be reported on VA Form 21P-8416, Medical Expense Report. This form contains
optional addendums that you may submit to supplement this form without the need to submit multiple copies of
VA Form 21P-8416. You may submit as many copies of each addendum as you need. If you leave the questions on the
addendum blank, VA will assume you are not submitting any additional medical expenses beyond the pages received.
• 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 VA by submitting a completed VA Form 21-4138, Statement in Support of Claim, or by
contacting our call center at 1-800-827-1000.
• VA can deduct allowable expenses paid by either you, your spouse (for Veterans) or other relative that is a constructive
member of the household.
NOTE: Constructive member means the expenses can be for a spouse in a nursing home, a child away at school, or a similar situation. The expenses
were incurred on behalf of the claimant or a relative of the claimant (not necessarily a dependent for VA purposes) who is a member or constructive
member of the claimant's household.

• If you are unsure whether VA can deduct a payment for a particular expense, furnish a complete description including the
purpose of the payment. VA will inform you if an expense cannot be deducted.
• If you are claiming vitamins, food supplements and/or herbal remedies, VA may allow these expense deductions on a
limited basis (per household member and calendar year). If the deductions are over the limit per household member, VA
requires evidence from a healthcare provider instructing the claimant or other dependent member of the household to
purchase vitamins, food supplements, and/or herbal remedies. Please ensure these expenses are listed separately per
household member.
VA FORM 21P-8416, XXX XXXX

Page 1

IMPORTANT INFORMATION (Continued)
• DO NOT submit receipts for medical expenses you paid. VA may require you to verify the amounts you paid in
some circumstances. Therefore, please keep all receipts or other documentation of payments for at least 3 years after
receiving 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.
• Submitting a new VA Form 21P-8416 without reporting a previously counted medical expense may result in removal of
the medical expense from the date of receipt of the form.
• If reporting expenses for a nursing home facility, please also submit VA Form 21-0779, Request for Nursing Home
Information in Connection with Claim for Aid and Attendance. Important - This only applies if your care facility is found
under the "Nursing homes including rehab services" section of the following website address:
https://www.medicare.gove/care-compare.
• If you are claiming expenses for an in-home care provider or for assisted living or similar care, each care provider should
complete the applicable worksheet for VA to determine whether all or some of your payments to the provider or facility are
deductible. The applicable worksheets are:
o Residential Care, Adult Daycare, or a Similar Facility - OR o In-Home Attendant Expenses
ASSISTANCE WITH COMPLETING YOUR CLAIM
Veteran Service Officer (VSO)
You may wish to contact an accredited Veterans Service Officer to assist you with your application. For a list of accredited
Veterans service organizations go to https://www.va.gov/vso/. You may also contact your state office of Veterans Affairs at
https://www.va.gov/statedva.htm, should you need further assistance with the application process. To assign a VSO as your
power of attorney for the claims process, please submit a VA Form 21-22, Appointment of Veterans Service Organization as
Claimant's Representative.
Private Attorney and Claims Agents
Attorneys and claims agents are available to assist you in completing your application. To verify if your attorney or claims
agent is accredited by the Department of Veteran Affairs, go to: https://www.va.gov/ogc/apps/accreditation/index.asp. To
assign a private attorney or claims agent as your power of attorney for the claims process, please submit VA Form 21-22a,
Appointment of Individual as Claimant's Representative.
Fees for Claims
Section 5904, Title 38, United States Code (codified in § 14.636, Title 38, Code of Federal Regulations) contains provisions
regarding fees that may be charged, allowed or paid for services provided by a VA- accredited attorney or agent in
connection with a proceeding before the Department of Veterans Affairs with respect to a claim for benefits under laws
administered by the department. Generally, a VA-accredited attorney or claims agent can ONLY charge claimants a fee after
the VA has issued an initial decision on a claim and the attorney or agent has complied with the applicable power-of-attorney
and the fee agreement requirements.
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 Veteran Readiness 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 their 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 21P-8416, XXX XXXX

Page 2

OMB Control No. 2900-0161
Respondent Burden: 30 minutes
Expiration Date: XX/XX/XXXX
VA DATE STAMP

(DO NOT WRITE IN THIS SPACE)

MEDICAL EXPENSE REPORT
SECTION I: VETERAN'S IDENTIFICATION INFORMATION
NOTE: You may either complete the form online or by hand. If completed by hand, print the information requested in ink, neatly, and legibly, to help
expedite processing of the form.
1A. NAME OF VETERAN (First, Middle Initial, Last)

FIRST:

MI:

1B. VETERAN'S SOCIAL SECURITY NUMBER

LAST:

1C. VA FILE NUMBER (If applicable)

SECTION II: CLAIMANT'S CONTACT INFORMATION
2A. NAME OF CLAIMANT (First, Middle Initial, Last - if different from veteran)

MI:

FIRST:

LAST:

2B. MAILING ADDRESS (Number and street or rural route, P. O. Box, City, State, ZIP Code and Country)

Apt./Unit Number

No. and Street
City

State/Province

Zip Code/Postal Code

Country

2C. PRIMARY TELEPHONE NUMBER (Include Area Code)
International Telephone Number (If applicable)
2D. CLAIMANT'S EMAIL ADDRESS (Optional)

Email Address

SECTION III: REPORTING PERIOD

This form is designed to provide VA with your medical expenses paid during a specific date range to determine or adjust your benefits. If you are
submitting an initial application, please only report medical expenses paid on or after your effective date. Your effective date is typically one of the
following dates:
• Date VA receives your initial application
• Date VA receives your VA Form 21-0966, Intent to File a Claim for Compensation and/or Pension, or Survivors Pension and/or DIC
• Date of the Veteran's death (for Survivors Pension, if within one year of the Veteran's death)
If you are already in receipt of Pension benefits, report medical expenses you paid on a calendar year basis (ex. 01/01/XXXX thru 12/31/XXXX). If you
are responding to a letter that identifies a specific date range, please report medical expenses you paid during the requested period(s).
Note: Submit separate VA Form 21P-8416's if reporting information for additional date ranges beyond a 1-year period.
3. THE INFORMATION SHOWN BELOW REPRESENTS MEDICAL EXPENSES PAID DURING THE FOLLOWING DATE RANGE:
Report amounts paid between the dates __________________ and ___________________ - OR-

DATE RECEIVED BY VA (For initial applications only)

SECTION IV: IN-HOME CARE AND CARE FACILITY EXPENSES
IMPORTANT: If you are claiming expenses for in-home care, residential care, adult daycare, or similar care facility; EACH provider must complete the
applicable worksheet(s) on pages 9 and 10, in addition to completion of this section. If you are reporting a nursing home found under the "Nursing
homes including rehab services" section of the https://www.medicare.gov/care-compare" website, you must submit VA Form 21-0779, Request for
Nursing Home Information in Connection with Claim for Aid and Attendance, instead of a worksheet.
4A. (3) PROVIDER START AND END DATE (MM/DD/YYYY)

4A (1). WHOSE EXPENSES WERE PAID?
SPOUSE

VETERAN

CHILD (Specify)

START:

OTHER (Specify)

NOTE: If ongoing leave end date blank.

Specify Name of Child or Other:________________________________________

END:

4A (2). NAME OF PROVIDER
4A (4). AMOUNT PAID MONTHLY

,

$

4A (5). IF THIS IS AN IN-HOME PROVIDER, PROVIDE RATE AND HOURS BELOW:
Payment Rate
(Per Hour)

.

$

.00

4B (1). WHOSE EXPENSES WERE PAID?
VETERAN

SPOUSE

4B. (3) PROVIDER START AND END DATE (MM/DD/YYYY)

CHILD (Specify)

OTHER (Specify)

START:
NOTE: If ongoing leave end date blank.

Specify Name of Child or Other:________________________________________

END:

4B (2). NAME OF PROVIDER
4B (4). AMOUNT PAID MONTHLY

$

,

Average Hours Worked
(Per Week)

.

4B (5). IF THIS IS AN IN-HOME PROVIDER, PROVIDE RATE AND HOURS BELOW:
Payment Rate
(Per Hour)

$

.00

Average Hours Worked
(Per Week)

NOTE: If you have additional in-home care or care facility expenses, complete Addendum A: In-Home Care or Care Facility Expenses on page 6.
VA FORM
XXX XXXX

21P-8416

SUPERSEDES VA FORM 21P-8416, DEC 2021

Page 3

SECTION V: OTHER MEDICAL EXPENSES

DO NOT report your monthly recurring expenses on multiple lines; rather, report recurring expenses on one line. For recurring expenses include the
specific dates the recurring expense started and calculated to either a monthly or annual rate. Complete an additional line for any changes in the amount
of a monthly recurring expense. If a recurring expense has already terminated, please treat the expense as non-recurring.
Non-recurring expenses must be reported individually on separate lines. Prescription medications are generally not considered recurring.
Note: A new VA Form 21P-8416 submitted without reporting a previously counted medical expense may result in removal of the medical expense from
the date of receipt of the form.
5A (1). WHOSE EXPENSES WERE PAID?
VETERAN

SPOUSE

CHILD (Specify)

5A (2). DATE COSTS INCURRED (MM/DD/YYYY)

OTHER (Specify)

Specify Name of Child or Other:______________________________________________

5A. (3). FREQUENCY
MONTHLY

5A. (4). AMOUNT YOU PAY

ANNUALLY

5A. (5). PAID TO (Name of provider, insurance company, etc.)

$

,

.

5A. (6). PURPOSE (Insurance premium, medical supplies, etc.)

5B (1). WHOSE EXPENSES WERE PAID?
VETERAN

SPOUSE

CHILD (Specify)

5B (2). DATE COSTS INCURRED (MM/DD/YYYY)

OTHER (Specify)

Specify Name of Child or Other:______________________________________________

5B. (3). FREQUENCY
MONTHLY

5B. (4). AMOUNT YOU PAY

ANNUALLY

$

,

.

5B. (6). PURPOSE (Insurance premium, medical supplies, etc.)

5B. (5). PAID TO (Name of provider, insurance company, etc.)

5C (1). WHOSE EXPENSES WERE PAID?
VETERAN

SPOUSE

CHILD (Specify)

5C (2). DATE COSTS INCURRED (MM/DD/YYYY)

OTHER (Specify)

Specify Name of Child or Other:______________________________________________

5C. (3). FREQUENCY
MONTHLY

5C. (4). AMOUNT YOU PAY

ANNUALLY

$

,

.

5C. (6). PURPOSE (Insurance premium, medical supplies, etc.)

5C. (5). PAID TO (Name of provider, insurance company, etc.)

5D (1). WHOSE EXPENSES WERE PAID?
VETERAN

SPOUSE

CHILD (Specify)

5D (2). DATE COSTS INCURRED (MM/DD/YYYY)

OTHER (Specify)

Specify Name of Child or Other:______________________________________________

5D. (3). FREQUENCY
MONTHLY

5D. (4). AMOUNT YOU PAY

ANNUALLY

$

,

.

5D. (6). PURPOSE (Insurance premium, medical supplies, etc.)

5D. (5). PAID TO (Name of provider, insurance company, etc.)

5E (1). WHOSE EXPENSES WERE PAID?
VETERAN

SPOUSE

CHILD (Specify)

5E (2). DATE COSTS INCURRED (MM/DD/YYYY)

OTHER (Specify)

Specify Name of Child or Other:______________________________________________

5E. (3). FREQUENCY
MONTHLY

5E. (4). AMOUNT YOU PAY

ANNUALLY

5E. (5). PAID TO (Name of provider, insurance company, etc.)

,

$

.

5E. (6). PURPOSE (Insurance premium, medical supplies, etc.)

5F (1). WHOSE EXPENSES WERE PAID?
VETERAN

SPOUSE

CHILD (Specify)

5F (2). DATE COSTS INCURRED (MM/DD/YYYY)

OTHER (Specify)

Specify Name of Child or Other:______________________________________________

5F. (3). FREQUENCY
MONTHLY

5F. (4). AMOUNT YOU PAY

ANNUALLY

$

,

.

5F. (6). PURPOSE (Insurance premium, medical supplies, etc.)

5F. (5). PAID TO (Name of provider, insurance company, etc.)

5G (1). WHOSE EXPENSES WERE PAID?
VETERAN

SPOUSE

CHILD (Specify)

5G (2). DATE COSTS INCURRED (MM/DD/YYYY)

OTHER (Specify)

5G. (3). FREQUENCY
MONTHLY

5G. (5). PAID TO (Name of provider, insurance company, etc.)

Specify Name of Child or Other:______________________________________________
5G. (4). AMOUNT YOU PAY

ANNUALLY

$

,

.

5G. (6). PURPOSE (Insurance premium, medical supplies, etc.)

NOTE: If you have additional mileage reimbursement to report, complete Addendum B: Other Medical Expenses on page 7.
VA FORM 21P-8416, XXX XXXX

Page 4

SECTION VI: MILEAGE
Report miles traveled for medical purposes (e.g. hospital, clinic, pharmacy, etc.) in a privately owned vehicle (POV) such as a car, truck or motorcycle.
Only report travel that occurred between the dates reported in question 3.
Note: Please report your monthly travel to the same facility on one line. Specific dates for the same facility are not necessary when reported monthly.
6A. (1). WHO NEEDED TO TRAVEL? (Self, spouse, child, etc.)
VETERAN

SPOUSE

CHILD (Specify)

OTHER (Specify)

6A. (3). TOTAL MILES
TRAVELED

6A. (4). DATE TRAVELED (MM/DD/YYYY
Month

Year

Day

Specify Name of Child or Other:_____________________________________
6A. (5). AMOUNT REIMBURSED FROM ANY SOURCE
(VA Medical Center, etc.)

6A. (2). PROVIDE LOCATION TRAVELED TO (Hospital, clinic, pharmacy, etc.)

$
6B. (1). WHO NEEDED TO TRAVEL? (Self, spouse, child, etc.)
VETERAN

SPOUSE

CHILD (Specify)

OTHER (Specify)

6B. (3). TOTAL MILES
TRAVELED

,

.

6B. (4). DATE TRAVELED (MM/DD/YYYY
Month

Year

Day

Specify Name of Child or Other:_____________________________________
6B. (5). AMOUNT REIMBURSED FROM ANY SOURCE
(VA Medical Center, etc.)

6B. (2). PROVIDE LOCATION TRAVELED TO (Hospital, clinic, pharmacy, etc.)

$
6C. (1). WHO NEEDED TO TRAVEL? (Self, spouse, child, etc.)
VETERAN

SPOUSE

CHILD (Specify)

OTHER (Specify)

6C. (3). TOTAL MILES
TRAVELED

,

.

6C. (4). DATE TRAVELED (MM/DD/YYYY
Month

Year

Day

Specify Name of Child or Other:_____________________________________
6C. (5). AMOUNT REIMBURSED FROM ANY SOURCE
(VA Medical Center, etc.)

6C. (2). PROVIDE LOCATION TRAVELED TO (Hospital, clinic, pharmacy, etc.)

$
6D. (1). WHO NEEDED TO TRAVEL? (Self, spouse, child, etc.)
VETERAN

SPOUSE

CHILD (Specify)

OTHER (Specify)

6D. (3). TOTAL MILES
TRAVELED

,

.

6D. (4). DATE TRAVELED (MM/DD/YYYY

Specify Name of Child or Other:_____________________________________
6D. (5). AMOUNT REIMBURSED FROM ANY SOURCE
(VA Medical Center, etc.)

6D. (2). PROVIDE LOCATION TRAVELED TO (Hospital, clinic, pharmacy, etc.)

$

,

.

NOTE: if you have additional mileage reimbursement to report, complete Addendum C: Mileage for Privately Owned Vehicle Travel for Medical Purposes
on page 8.

SECTION VII: CERTIFICATION AND SIGNATURE

CERTIFICATION: I have not and will not receive reimbursement for these expenses. I certify the information contained on this form and the
attached addendums is a true representation of expenses I have paid.
7A. SIGNATURE OF CLAIMANT/AUTHORIZED REPRESENTATIVE (Sign in ink)

7B. DATE SIGNED (MM/DD/YYYY)

SECTION VIII: WITNESS TO SIGNATURE
(Two (2) witness signatures are required if claimant signed Item 7A with an "X"
8A. PRINTED NAME OF FIRST WITNESS (Note: Only to be used if claimant
signed in Item 7A using an "X")

8B. SIGNATURE OF FIRST WITNESS (NOTE: Only used if claimant
signed in 7A using an "X")

8C. MAILING ADDRESS OF FIRST WITNESS
No. and Street
City

Apt../Unit Number
State/Province

8D. PRINTED NAME OF SECOND WITNESS (Note: Only to be used if claimant
signed in Item 7A using an "X")

Country

Zip Code/Postal Code

8E. SIGNATURE OF SECOND WITNESS (NOTE: Only used if claimant
signed in 7A using an "X")

8F. MAILING ADDRESS OF SECOND WITNESS
No. and Street
City

Apt../Unit Number
State/Province

Country

Zip Code/Postal Code

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 payment you are not entitled to.
VA FORM 21P-8416, XXX XXXX

Page 5

ADDENDUM A: IN-HOME CARE OR CARE FACILITY EXPENSES
If you are not claiming expenses related to a care facility or from an in-home care provider, completion of Addendum A is not required.
IMPORTANT: If you are claiming expenses for in-home care, residential care, adult daycare, or similar care facility; EACH provider must complete the
applicable worksheet(s) on pages 9 and 10, in addition to completion of this section. If you are reporting a nursing home, you must submit VA Form
21-0779, Request for Nursing Home Information in Connection with Claim for Aid and Attendance.
1C. PROVIDER START AND END DATE (MM/DD/YYYY)

1A. WHOSE EXPENSES WERE PAID?
SPOUSE

VETERAN

CHILD (Specify)

START:

OTHER (Specify)

NOTE: If ongoing leave end date blank.

Specify Name of Child or Other:________________________________________

END:

1B. NAME OF PROVIDER
1D. AMOUNT PAID MONTHLY

$

,

1E. IF THIS IS AN IN-HOME PROVIDER, PROVIDE RATE AND HOURS BELOW

.

Payment Rate
(Per Hour)

$

.00

2C. PROVIDER START AND END DATE (MM/DD/YYYY)

2A. WHOSE EXPENSES WERE PAID?
SPOUSE

VETERAN

CHILD (Specify)

START:

OTHER (Specify)

NOTE: If ongoing leave end date blank.

Specify Name of Child or Other:________________________________________

END:

2B. NAME OF PROVIDER
2D. AMOUNT PAID MONTHLY

,

$

2E. IF THIS IS AN IN-HOME PROVIDER, PROVIDE RATE AND HOURS BELOW

.

Payment Rate
(Per Hour)

$

.00

3A. WHOSE EXPENSES WERE PAID?
SPOUSE

VETERAN

START:

OTHER (Specify)

NOTE: If ongoing leave end date blank.
END:

3B. NAME OF PROVIDER
3D. AMOUNT PAID MONTHLY

,

3E. IF THIS IS AN IN-HOME PROVIDER, PROVIDE RATE AND HOURS BELOW

.

Payment Rate
(Per Hour)

$

.00

SPOUSE

CHILD (Specify)

START:

OTHER (Specify)

NOTE: If ongoing leave end date blank.

Specify Name of Child or Other:________________________________________

END:

4B. NAME OF PROVIDER

4E. IF THIS IS AN IN-HOME PROVIDER, PROVIDE RATE AND HOURS BELOW

4D. AMOUNT PAID MONTHLY

,

$

.

Payment Rate
(Per Hour)

$

.00

5A. WHOSE EXPENSES WERE PAID?
SPOUSE

VETERAN

START:

OTHER (Specify)

NOTE: If ongoing leave end date blank.
END:

5B. NAME OF PROVIDER
5D. AMOUNT PAID MONTHLY

,

5E. IF THIS IS AN IN-HOME PROVIDER, PROVIDE RATE AND HOURS BELOW

.

Payment Rate
(Per Hour)

$

.00

6A. WHOSE EXPENSES WERE PAID?
SPOUSE

VETERAN

CHILD (Specify)

START:

OTHER (Specify)

NOTE: If ongoing leave end date blank.
END:

6B. NAME OF PROVIDER
6D. AMOUNT PAID MONTHLY

,

VA FORM 21P-8416, XXX XXXX

Average Hours Worked
(Per Week)
6C. PROVIDER START AND END DATE (MM/DD/YYYY)

Specify Name of Child or Other:________________________________________

$

Average Hours Worked
(Per Week)
5C. PROVIDER START AND END DATE (MM/DD/YYYY)

CHILD (Specify)

Specify Name of Child or Other:________________________________________

$

Average Hours Worked
(Per Week)
4C. PROVIDER START AND END DATE (MM/DD/YYYY)

4A. WHOSE EXPENSES WERE PAID?
VETERAN

Average Hours Worked
(Per Week)
3C. PROVIDER START AND END DATE (MM/DD/YYYY)

CHILD (Specify)

Specify Name of Child or Other:________________________________________

$

Average Hours Worked
(Per Week)

6E. IF THIS IS AN IN-HOME PROVIDER, PROVIDE RATE AND HOURS BELOW

.

Payment Rate
(Per Hour)

$

.00

Average Hours Worked
(Per Week)

Page 6

ADDENDUM B: OTHER MEDICAL EXPENSES

If you are not claiming additional expenses, completion of Addendum B is not required.

Please report your monthly recurring expenses that are not reported in other sections on one line, including the specific dates the recurring expense started, and
calculated to either a monthly or annual rate. Complete an additional line for any changes in the amount of a monthly recurring expense. Prescription medications are
generally not considered recurring. If a recurring expense has already stopped, please treat the expense as non-recurring and report a total amount paid during the
designated time period.
Note: A new VA Form 21P-8416 submitted without reporting a previously counted medical expense may result in removal of the medical expense from the date of
receipt of the form.
1A. WHOSE EXPENSES WERE PAID?
VETERAN

SPOUSE

CHILD (Specify)

1B. DATE COSTS INCURRED (MM/DD/YYYY)

OTHER (Specify)

Specify Name of Child or Other:______________________________________________

1C. FREQUENCY
MONTHLY

1D. AMOUNT YOU PAY
ANNUALLY

NOT RECURRING

$

,

.

1F. PURPOSE (Insurance premium, medical supplies, etc.)

1E. PAID TO (Name of provider, insurance company, etc.)

2A. WHOSE EXPENSES WERE PAID?
VETERAN

SPOUSE

CHILD (Specify)

2B. DATE COSTS INCURRED (MM/DD/YYYY)

OTHER (Specify)

Specify Name of Child or Other:______________________________________________

2C. FREQUENCY
MONTHLY

2D. AMOUNT YOU PAY
ANNUALLY

NOT RECURRING

$

,

.

2F. PURPOSE (Insurance premium, medical supplies, etc.)

2E. PAID TO (Name of provider, insurance company, etc.)

3A. WHOSE EXPENSES WERE PAID?
VETERAN

SPOUSE

CHILD (Specify)

3B. DATE COSTS INCURRED (MM/DD/YYYY)

OTHER (Specify)

Specify Name of Child or Other:______________________________________________

3C. FREQUENCY
MONTHLY

3D. AMOUNT YOU PAY
ANNUALLY

NOT RECURRING

$

,

.

3F. PURPOSE (Insurance premium, medical supplies, etc.)

3E. PAID TO (Name of provider, insurance company, etc.)

4A. WHOSE EXPENSES WERE PAID?
VETERAN

SPOUSE

CHILD (Specify)

4B. DATE COSTS INCURRED (MM/DD/YYYY)

OTHER (Specify)

Specify Name of Child or Other:______________________________________________

4C. FREQUENCY
MONTHLY

4D. AMOUNT YOU PAY
ANNUALLY

NOT RECURRING

$

,

.

1F. PURPOSE (Insurance premium, medical supplies, etc.)

4E. PAID TO (Name of provider, insurance company, etc.)

5A. WHOSE EXPENSES WERE PAID?
VETERAN

SPOUSE

CHILD (Specify)

5B. DATE COSTS INCURRED (MM/DD/YYYY)

OTHER (Specify)

Specify Name of Child or Other:______________________________________________

5C. FREQUENCY
MONTHLY

5D. AMOUNT YOU PAY
ANNUALLY

5E. PAID TO (Name of provider, insurance company, etc.)

NOT RECURRING

$

,

.

5F. PURPOSE (Insurance premium, medical supplies, etc.)

6A. WHOSE EXPENSES WERE PAID?
VETERAN

SPOUSE

CHILD (Specify)

6B. DATE COSTS INCURRED (MM/DD/YYYY)

OTHER (Specify)

Specify Name of Child or Other:______________________________________________

6C. FREQUENCY
MONTHLY

6D. AMOUNT YOU PAY
ANNUALLY

6E. PAID TO (Name of provider, insurance company, etc.)

NOT RECURRING

$

,

.

6F. PURPOSE (Insurance premium, medical supplies, etc.)

7A. WHOSE EXPENSES WERE PAID?
VETERAN

SPOUSE

CHILD (Specify)

7B. DATE COSTS INCURRED (MM/DD/YYYY)

OTHER (Specify)

7C. FREQUENCY
MONTHLY

7E. PAID TO (Name of provider, insurance company, etc.)

VA FORM 21P-8416, XXX XXXX

Specify Name of Child or Other:______________________________________________
7D. AMOUNT YOU PAY

ANNUALLY

NOT RECURRING

$

,

.

7F. PURPOSE (Insurance premium, medical supplies, etc.)

Page 7

ADDENDUM C: MILEAGE FOR PRIVATELY OWNED VEHICLE TRAVEL FOR MEDICAL PURPOSES
Report miles traveled for medical purposes (e.g. hospital, clinic, pharmacy, etc.) in a privately owned vehicle (POV) such as a car, truck or motorcycle.
Only report travel that occurred between the dates reported in question 3 of VA Form 21P-8416, Medical Expense Report submitted with this addendum.
Note: Please report your monthly travel to the same facility on one line. Specific dates for the same facility are not necessary when reported monthly.
1A. WHO NEEDED TO TRAVEL? (Self, spouse, child, etc.)
VETERAN

SPOUSE

CHILD (Specify)

OTHER (Specify)

1C. TOTAL MILES
TRAVELED

1D. DATE TRAVELED (MM/DD/YYYY
Month

Year

Day

Specify Name of Child or Other:_____________________________________
1E. AMOUNT REIMBURSED FROM ANY SOURCE
(VA Medical Center, etc.)

1B. PROVIDE LOCATION TRAVELED TO (Hospital, clinic, pharmacy, etc.)

$
2A. WHO NEEDED TO TRAVEL? (Self, spouse, child, etc.)
VETERAN

SPOUSE

CHILD (Specify)

OTHER (Specify)

2C. TOTAL MILES
TRAVELED

,

.

2D. DATE TRAVELED (MM/DD/YYYY
Month

Year

Day

Specify Name of Child or Other:_____________________________________
2E. AMOUNT REIMBURSED FROM ANY SOURCE
(VA Medical Center, etc.)

2B. PROVIDE LOCATION TRAVELED TO (Hospital, clinic, pharmacy, etc.)

$
3A. WHO NEEDED TO TRAVEL? (Self, spouse, child, etc.)
VETERAN

SPOUSE

CHILD (Specify)

OTHER (Specify)

3C. TOTAL MILES
TRAVELED

,

.

3D. DATE TRAVELED (MM/DD/YYYY
Month

Year

Day

Specify Name of Child or Other:_____________________________________
3E. AMOUNT REIMBURSED FROM ANY SOURCE
(VA Medical Center, etc.)

3B. PROVIDE LOCATION TRAVELED TO (Hospital, clinic, pharmacy, etc.)

$
4A. WHO NEEDED TO TRAVEL? (Self, spouse, child, etc.)
VETERAN

SPOUSE

CHILD (Specify)

OTHER (Specify)

4C. TOTAL MILES
TRAVELED

,

.

4D. DATE TRAVELED (MM/DD/YYYY

Specify Name of Child or Other:_____________________________________
4E. AMOUNT REIMBURSED FROM ANY SOURCE
(VA Medical Center, etc.)

4B. PROVIDE LOCATION TRAVELED TO (Hospital, clinic, pharmacy, etc.)

$
5A. WHO NEEDED TO TRAVEL? (Self, spouse, child, etc.)
VETERAN

SPOUSE

CHILD (Specify)

OTHER (Specify)

5C. TOTAL MILES
TRAVELED

,

.

5D. TRAVELED (MM/DD/YYYY
Month

Year

Day

Specify Name of Child or Other:_____________________________________
5E. AMOUNT REIMBURSED FROM ANY SOURCE
(VA Medical Center, etc.)

5B. PROVIDE LOCATION TRAVELED TO (Hospital, clinic, pharmacy, etc.)

$
6A. WHO NEEDED TO TRAVEL? (Self, spouse, child, etc.)
VETERAN

SPOUSE

CHILD (Specify)

OTHER (Specify)

6C. TOTAL MILES
TRAVELED

,

.

6D. DATE TRAVELED (MM/DD/YYYY
Month

Year

Day

Specify Name of Child or Other:_____________________________________
6E. AMOUNT REIMBURSED FROM ANY SOURCE
(VA Medical Center, etc.)

6B. PROVIDE LOCATION TRAVELED TO (Hospital, clinic, pharmacy, etc.)

$
7A. WHO NEEDED TO TRAVEL? (Self, spouse, child, etc.)
VETERAN

SPOUSE

CHILD (Specify)

OTHER (Specify)

7C. TOTAL MILES
TRAVELED

,

.

7D. DATE TRAVELED (MM/DD/YYYY
Month

Year

Day

Specify Name of Child or Other:_____________________________________
7E. AMOUNT REIMBURSED FROM ANY SOURCE
(VA Medical Center, etc.)

7B. PROVIDE LOCATION TRAVELED TO (Hospital, clinic, pharmacy, etc.)

$
8A. WHO NEEDED TO TRAVEL? (Self, spouse, child, etc.)
VETERAN

SPOUSE

CHILD (Specify)

OTHER (Specify)

8C. TOTAL MILES
TRAVELED

,

.

8D. DATE TRAVELED (MM/DD/YYYY

Specify Name of Child or Other:_____________________________________
8B. PROVIDE LOCATION TRAVELED TO (Hospital, clinic, pharmacy, etc.)

8E. AMOUNT REIMBURSED FROM ANY SOURCE
(VA Medical Center, etc.)
$

VA FORM 21P-8416, XXX XXXX

,

.

Page 8

WORKSHEET FOR A RESIDENTIAL CARE, ADULT DAYCARE, OR A SIMILAR FACILITY
NOTE: This worksheet is to be completed by an administrator or licensed medical professional from a residential care, adult daycare, or similar facility. To
count this medical provider as an expense, they must be claimed on your application for benefits or VA Form 21P-8416, Medical Expense Report. In
addition, VA Form 21-2680, Examination for Housebound Status or Permanent Need for Regular Aid and Attendance may be needed to count these
expenses.

1. WHO ARE YOU COMPLETING THIS WORKSHEET FOR? (Name of Care Recipient, either the Claimant or Dependent)

2. WHO IS COMPLETING THIS WORKSHEET? (Name of Provider, either an Administrator or Licensed Medical Professional)

3. WHAT ROLE OR POSITION DO YOU PERFORM AT THE FACILITY?

4. WHAT IS THE NAME OF THE FACILITY? (As shown on facility license or official website)

International Phone Number (If applicable)

5. WHAT IS THE FACILITY TELEPHONE NUMBER?

6. WHAT IS THE MAILING ADDRESS OF THE FACILITY'S ADMINISTRATIVE OFFICE?
No. &
Street
City

Apt./Unit Number
State/Province

Country

ZIP Code

7. WHAT IS THE FACILITY'S WEBSITE ADDRESS?
8. PLEASE SELECT EACH ACTIVITY OF DAILY LIVING (ADL) THAT THE FACILITY IS PROVIDING TO THE CARE RECIPIENT.
A. EATING

B. BATHING/SHOWERING

C. TRANSFERRING IN OR OUT OF BED OR CHAIR

D. DRESSING

E. USING THE TOILET

F. AMBULATING WITHIN HOME OR LIVING AREA

9. FOR EACH STATEMENT BELOW PLEASE CHECK THE BOX IF THIS STATEMENT IS TRUE FOR THE FACILITY:
THE STATE OR COUNTRY REQUIRES THIS FACILITY TO BE LICENSED
THE FACILITY IS LICENSED
THE FACILITY IS RESIDENTIAL
THE FACILITY IS STAFFED 24 HOURS
10. DOES THE FACILITY'S STAFF PROVIDE THE CARE RECIPIENT WITH HEALTH CARE OR CUSTODIAL CARE OR BOTH.
(Custodial Care is regular assistance with two or more ADLs (Question 8), or supervision because an individual with a physical, mental, developmental, or cognitive disorder
requires care or assistance on a regular basis to protect the individual from hazards or dangers incident to their daily environment.)
YES

NO, Care is being provided by a third-party provider.

NO, Care is not being provided to this claimant.

If care is provided by a third-party provider, please ensure the claimant has each In-Home provider complete an In-Home Attendant Worksheet.
11. PLEASE PROVIDE THE DATE OF ADMISSION FOR THE CARE RECIPIENT
STAYING AT THE FACILITY. (MM/DD/YYYY)

12. ON WHAT DATE DO YOU EXPECT THIS CARE TO END? (MM/DD/YYYY)
(Select "Indefinite" if the care you provide is not temporary.)
INDEFINITE

13. PLEASE PROVIDE THE MONTHLY CHARGES THE CARE RECIPIENT STAYING AT THE FACILITY IS RESPONSIBLE FOR PAYING.
$

,

.

PER MONTH

FACILITY CERTIFICATION
I CERTIFY that the information stated within this WORKSHEET FOR A RESIDENTIAL CARE, ADULT DAYCARE, OR SIMILAR FACILITY is accurate and
reflects the current environment of the Care Recipient and the facility.
14. SIGNATURE OF PROVIDER (From question 2)

VA FORM 21P-8416, XXX XXXX

15. DATE SIGNED (MM/DD/YYYY)

Page 9

WORKSHEET FOR IN-HOME ATTENDANT EXPENSES
NOTE: This worksheet is to be completed by your in-home care provider -OR- if an agency is providing you in-home care please have an agency
administrator complete this form. These expenses must be claimed on your application for benefits or VA Form 21P-8416, Medical Expense Report. In
addition, VA Form 21-2680, Examination for Housebound Status or Permanent Need for Regular Aid and Attendance may be needed to count these
expenses.

1. WHO ARE YOU COMPLETING THIS WORKSHEET FOR? (Name of Care Recipient, either the Claimant or Dependent)

2. WHO IS COMPLETING THIS WORKSHEET? (In-Home Care Attendant or Agency Administrator, Provider)

4. DO YOU WORK FOR AN AGENCY OR
ORGANIZATION?

3. IS THE IN-HOME CARE PROVIDED BY A LICENSED MEDICAL PROFESSIONAL?
(A licensed health care provider refers to a person licensed to furnish health services by the State or country
in which the services are provided.)
YES

NO

YES

5. WHAT IS THE NAME OF THE AGENCY OR ORGANIZATION?

NO (If "NO," skip to question 7)

6. WHAT IS THE AGENCY TELEPHONE NUMBER?

7. WHAT IS YOUR MAILING ADDRESS OR THAT OF YOUR AGENCY'S ADMINISTRATIVE OFFICE?
No. &
Street
Apt./Unit Number

City

State/Province

Country

ZIP Code

8. PLEASE SELECT EACH ACTIVITY OF DAILY LIVING (ADL) THAT THE IN-HOME CARE ASSISTANT PROVIDED TO THE CARE RECIPIENT.
A. EATING

B. BATHING/SHOWERING

C. TRANSFERRING IN OR OUT OF BED OR CHAIR

D. DRESSING

E. USING THE TOILET

F. AMBULATING WITHIN HOME OR LIVING AREA

9. PLEASE SELECT EACH INSTRUMENTAL ACTIVITY OF DAILY LIVING (IADL) THAT THE IN-HOME CARE ASSISTANT PROVIDES TO THE CARE RECIPIENT.
A. SHOPPING

B. FOOD PREPARATION

C. NON-MEDICAL TRANSPORTATION

D. LAUNDERING

E. USING TELEPHONE

F. MANAGING FINANCES

G. HOUSEKEEPING

H. HANDLING MEDICATIONS

10. IS THE PRIMARY RESPONSIBILITY OF THE IN-HOME ATTENDANT TO PROVIDE THE CARE RECIPIENT WITH HEALTH CARE OR CUSTODIAL CARE? (Custodial
Care is regular assistance with two or more ADLs (Question 8), or supervision because an individual with a physical, mental, developmental, or cognitive disorder requires care
or assistance on a regular basis to protect the individual from hazards or dangers incident to their daily environment.)
YES

NO

11. PLEASE PROVIDE THE DATE CARE BEGAN FOR THE
CARE RECIPIENT. (MM/DD/YYYY)

12. ON WHAT DATE DO YOU EXPECT THIS CARE TO END? (MM/DD/YYYY)
(Select "Indefinite" if the care you provide is not temporary.)
INDEFINITE

13. PLEASE PROVIDE THE HOURLY CHARGES THE CARE RECIPIENT IS
RESPONSIBLE FOR PAYING.

$

.

14. PLEASE PROVIDE THE TOTAL HOURS PER MONTH THAT YOU PROVIDE
CARE TO THE CARE RECIPIENT.
HOURS PER MONTH

PER HOUR

CERTIFICATION
I CERTIFY that the information stated within this WORKSHEET FOR IN-HOME ATTENDANT EXPENSES is accurate and reflects the current environment
of the care recipient and the care services listed in questions eight and nine (8-9) above.
15. SIGNATURE OF PROVIDER (From question 2)

VA FORM 21P-8416, XXX XXXX

16. DATE SIGNED (MM/DD/YYYY)

Page 10