Fillable INSTRUCTIONS FOR MEDICAL EXPENSE REPORT VA may be (Senior Veterans Service Alliance)

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INSTRUCTIONS FOR MEDICAL EXPENSE REPORT VA may be (Senior Veterans Service Alliance)

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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.
SUPERSEDES VA FORM 21P-8416, JAN 2017,
WHICH WILL NOT BE USED.
21P-8416
VA FORM
OCT 2018
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 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.
• 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.
• If you are a veteran, VA can deduct allowable expenses paid by either you or your spouse.
• If you are claiming expenses for an in-home care provider or for assisted living or similar care, you must complete
the appropriate worksheet on page 5 or 6 to determine whether VA may deduct all or some of your payments to the
provider or facility.
Page 1
9. MILEAGE FOR PRIVATELY OWNED VEHICLE TRAVEL FOR MEDICAL PURPOSES
A. MEDICAL FACILITY TO WHICH
TRAVELED
7. TELEPHONE NUMBER OF CLAIMANT (Include Area Code)
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).
VA FORM
OCT 2018
21P-8416
OMB Control No. 2900-0161
Respondent Burden: 30 minutes
Expiration Date: 10/31/2021
SUPERSEDES VA FORM 21P-8416, JAN 2017.
3. VA FILE NUMBER (If applicable)
8. E-MAIL ADDRESS
1. NAME OF VETERAN (First, Middle Initial, Last)
IMPORTANT: Be sure to sign and date this form in Items 12A & 12B on page 4. Unsigned reports will be returned.
MEDICAL EXPENSE REPORT
2. SOCIAL SECURITY NUMBER
4. NAME OF CLAIMANT (First, Middle Initial, Last)
Page 2
D. DATE
TRAVELED
(Month/Day/Year)
E. WHO NEEDED TO
TRAVEL?
(Self, spouse, child)
C. AMOUNT REIMBURSED
FROM ANOTHER SOURCE
(Such as a VA Medical Center)
B. TOTAL ROUNDTRIP
MILES TRAVELED
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.
VA DATE STAMP
(DO NOT WRITE IN THIS SPACE)
5. CURRENT MAILING ADDRESS OF CLAIMANT (Number and street or rural route, P. O. Box, City, State, ZIP Code and Country)
ZIP Code/Postal Code
Country
State/Province
City
Apt./Unit Number
No. &
Street
Enter International Phone Number
(If applicable)
6. CHANGE OF ADDRESS (Check box if address is different from last address furnished to VA)
YES
NO
Month
Day
Year
Month
Day
Year
Month
Day
Year
Month
Day
Year
Month
Day
Year
Month
Day
Year
MEDICARE (PART D)
A. NAME OF PROVIDER
C. AMOUNT PAID
10. IN-HOME ATTENDANT EXPENSES
11. ITEMIZATION OF MEDICAL 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).
D. DATE PAID
(Month/Day/Year)
B. HOURLY RATE/
NUMBER OF HOURS
E. FOR WHOM PAID
(Self, spouse, child, etc.)
VA FORM 21P-8416, OCT 2018
Page 3
C. DATE PAID
(Month/Day/Year)
B. AMOUNT PAID
E. FOR WHOM PAID
(Self, spouse, child, etc.)
A. MEDICAL EXPENSE (Physician or
Hospital Charges, Eyeglasses, Oxygen
Rental, Medical Insurance, etc.)
D. NAME OF PROVIDER
(Name of doctor, dentist,
hospital, lab, etc.)
MEDICARE (PART B)
PRIVATE MEDICAL INSURANCE
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).
Month
Day
Year
Month
Day
Year
Month
Day
Year
Month
Day
Year
Month
Day
Year
Month Day
Year
Month Day
Year
Month Day
Year
Month Day
Year
Month Day
Year
Month Day
Year
Month Day
Year
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).
12A. SIGNATURE OF CLAIMANT (Do NOT print) 12B. DATE SIGNED
CERTIFICATION: I have not and will not receive reimbursement for these expenses. I certify that the above information is true.
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.
11. ITEMIZATION OF MEDICAL EXPENSES (Continued)
VA FORM 21P-8416, OCT 2018
Page 4
MEDICARE (PART D)
C. DATE PAID
(Month/Day/Year)
B. AMOUNT PAID
E. FOR WHOM PAID
(Self, spouse, child, etc.)
A. MEDICAL EXPENSE (Physician or
Hospital Charges, Eyeglasses, Oxygen
Rental, Medical Insurance, etc.)
D. NAME OF PROVIDER
(Name of doctor, dentist,
hospital, lab, etc.)
MEDICARE (PART B)
PRIVATE MEDICAL INSURANCE
Month Day
Year
Month Day
Year
Month Day
Year
Month Day
Year
Month Day
Year
Month Day
Year
Month Day
Year
Month
Day
Year
Month Day
Year
Month Day
Year
Month Day
Year
Month Day
Year
STEP 7. Is the primary responsibility of the in-home attendant to provide the disabled person with health care and/or custodial care?
NOTE: Only complete this worksheet if you are claiming expenses for in-home care.
(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 10. Skip to Step 8)
STEP 3. Is the primary responsibility of the in-home attendant to provide you with health care services or custodial care?
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?
STEP 1. Are you (the claimant) the disabled person?
STEP 8. Check all activities below that the attendant assists the disabled person with:
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.
STEP 4. Are you claiming special monthly pension?
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)
WORKSHEET FOR IN-HOME ATTENDANT EXPENSES
Page 5
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
(If "NO," skip to Step 6)
(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 10. Skip to Step 8)
(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 10. Skip
to Step 8)
STEP 5. Is the primary responsibility of the in-home attendant to provide you with health care or custodial care?
(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 10 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)
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 from________________________________.
(Name of Person Requiring Care)
(Name of Attendant)
(Name, Signature and Title of Certifying Official)
(Date Certified)
(If "NO," payments to this in-home attendant for assistance with IADLs do not qualify as medical expenses. Please report separately in
Item 10 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)
ADLs:
IADLs:
(If "YES," the attendant does not need to be a health care provider. Skip to Step 3)
(If "NO," skip to Step 4)
(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 10. Skip to Step 8)
(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 10)
(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 10)
VA FORM 21P-8416, OCT 2018
YES
NO
NO
YES
NO
YES
NO
YES
NO
YES
NO
YES
NO
YES
USING THE TOILET
EATING
BATHING/SHOWERING
DRESSING
TRANSFERRING
SHOPPING
FOOD PREPARATION
HOUSEKEEPING
LAUNDRY
MANAGING FINANCES
HANDLING MEDICATIONS
USING THE TELEPHONE
TRANSPORTATION FOR NON-MEDICAL PURPOSES
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
facility_____________________________________________________________________.
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?
STEP 10. Facility Certification: Please submit a current statement showing the fees claimant pays to your facility and breakdown of the care received.
WORKSHEET FOR AN ASSISTED LIVING, ADULT DAY CARE, OR A SIMILAR FACILITY
Page 6
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?
(If "NO," payments to the facility do not qualify as medical expenses. You are finished completing this worksheet)
(If "YES," all payments to the facility qualify as medical expenses. You may claim these expenses in Item 11.
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
STEP 3. Are you (the claimant) the disabled person? Are you a veteran, surviving spouse, or Parents' DIC claimant?
(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)
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)?
(If "YES," all payments to this facility qualify as medical expenses. You may claim these expenses in Item 11. Skip to Step 10)
STEP 6. Are you claiming special monthly pension?
(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 11. 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)?
(If "NO," payments to this facility for meals and lodging do not qualify as medical expenses. Please report separately in Item 11
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)
(If "NO," continue to Step 2)
(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)
(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 11 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)
(Name of person staying at your facility)
(Name and address of facility)
(Name, Signature and Title of Person Certifying for the Facility)
(Date Certified)
(If "NO," skip to Step 6)
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?
(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 11. Skip to Step 10)
(If "YES," claim all payments to this facility (to include meals and lodging) as medical expenses in Item 11)
(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 11)
VA FORM 21P-8416, OCT 2018
NO
YES
NO
YES
NO
YES
NO
YES
NO
YES
NO
YES
NO
YES
NO
YES
NO
YES
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INSTRUCTIONS FOR MEDICAL EXPENSE REPORT VA may be (Senior Veterans Service Alliance)

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Completed 24 August 2020

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