VA Form 21P-8416, Medical Expense Report

• 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 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 • Nursing home costs

• Doctor's office fees • Hearing aid costs

• Dental fees • Home health service expenses

• Prescription/non-prescription drug costs • Expenses related to transportation to a hospital, doctor or other

• Vision care costs medical facility

• Medical insurance premiums • Monthly Medicare deduction

Page 1

VA FORM 21P-8416, OCT 2023

INSTRUCTIONS FOR MEDICAL EXPENSE REPORT

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 V: OTHER MEDICAL EXPENSES

SECTION VI: MILEAGE

SECTION VII: CERTIFICATION AND SIGNATURE

SECTION VIII: WITNESS TO SIGNATURE

SECTION IV: IN-HOME CARE AND CARE FACILITY EXPENSES

This form contains the following addendums and worksheets that may be required to support your application:

Addendum: Worksheet:

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

• B: Other Medical Expenses Continued • In-Home Attendant Expenses

• C: Mileage Traveled for Medical Purposes Using

Privately Owned Vehicle

IMPORTANT INFORMATION

VA FORM 21P-8416, OCT 2023

Page 2

• 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 continuing 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.

IMPORTANT INFORMATION (Continued)

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.

Specify Name of Child or Other:________________________________________

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.

OMB Control No. 2900-0161

Respondent Burden: 30 minutes

Expiration Date: 10/31/2026

1C. VA FILE NUMBER (If applicable)

1A. NAME OF VETERAN (First, Middle Initial, Last)

MEDICAL EXPENSE REPORT

1B. VETERAN'S SOCIAL SECURITY NUMBER

Page 3

VA DATE STAMP

(DO NOT WRITE IN THIS SPACE)

SUPERSEDES VA FORM 21P-8416, DEC 2021

21P-8416

VA FORM

OCT 2023

FIRST:

MI:

LAST:

SECTION I: VETERAN'S IDENTIFICATION INFORMATION

SECTION II: CLAIMANT'S CONTACT INFORMATION

2A. NAME OF CLAIMANT (First, Middle Initial, Last - if different from veteran)

FIRST:

MI:

LAST:

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.

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 Country

Zip Code/Postal Code

2C. PRIMARY TELEPHONE NUMBER (Include Area Code)

International Telephone Number (If applicable)

2D. CLAIMANT'S EMAIL ADDRESS (Optional)

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 the earliest

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

4A (1). WHOSE EXPENSES WERE PAID?

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

NOTE: If care is ongoing leave end date blank.

START:

END:

VETERAN

SPOUSE

CHILD (Specify)

OTHER (Specify)

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

Average Hours Worked

(Per Week)

Specify Name of Child or Other:________________________________________

4B (1). WHOSE EXPENSES WERE PAID?

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

NOTE: If care is ongoing leave end date blank.

START:

END:

VETERAN

SPOUSE

CHILD (Specify)

OTHER (Specify)

4B (2). NAME OF PROVIDER

4B (4). AMOUNT PAID MONTHLY

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

Payment Rate

(Per Hour)

$ .00

Average Hours Worked

(Per Week)

VA FORM 21P-8416, OCT 2023

Page 4

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 continuing medical expense may result in removal of the medical

expense from the date of receipt of the form.

Specify Name of Child or Other:______________________________________________

5A (1). WHOSE EXPENSES WERE PAID?

VETERAN

SPOUSE

CHILD (Specify)

OTHER (Specify)

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

5A. (3). FREQUENCY

5A. (4). PAYMENT AMOUNT

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

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

Specify Name of Child or Other:______________________________________________

5B (1). WHOSE EXPENSES WERE PAID?

VETERAN

SPOUSE

CHILD (Specify)

OTHER (Specify)

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

5B. (3). FREQUENCY

5B. (4). PAYMENT AMOUNT

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

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

Specify Name of Child or Other:______________________________________________

5C (1). WHOSE EXPENSES WERE PAID?

VETERAN

SPOUSE

CHILD (Specify)

OTHER (Specify)

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

5C. (3). FREQUENCY

5C. (4). PAYMENT AMOUNT

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

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

Specify Name of Child or Other:______________________________________________

5D (1). WHOSE EXPENSES WERE PAID?

VETERAN

SPOUSE

CHILD (Specify)

OTHER (Specify)

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

5D. (3). FREQUENCY

5D. (4). PAYMENT AMOUNT

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

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

Specify Name of Child or Other:______________________________________________

5E (1). WHOSE EXPENSES WERE PAID?

VETERAN

SPOUSE

CHILD (Specify)

OTHER (Specify)

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

5E. (3). FREQUENCY

5E. (4). PAYMENT AMOUNT

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

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

Specify Name of Child or Other:______________________________________________

5F (1). WHOSE EXPENSES WERE PAID?

VETERAN

SPOUSE

CHILD (Specify)

OTHER (Specify)

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

5F. (3). FREQUENCY

5F. (4). PAYMENT AMOUNT

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

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

Specify Name of Child or Other:______________________________________________

5G (1). WHOSE EXPENSES WERE PAID?

VETERAN

SPOUSE

CHILD (Specify)

OTHER (Specify)

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

5G. (3). FREQUENCY

5G. (4). PAYMENT AMOUNT

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

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

NOTE: If you have additional medical expenses to report, complete Addendum B: Other Medical Expenses on page 7.

MONTHLY

ANNUALLY

NOT RECURRING

MONTHLY

ANNUALLY

NOT RECURRING

MONTHLY

ANNUALLY

NOT RECURRING

MONTHLY

ANNUALLY

NOT RECURRING

MONTHLY

ANNUALLY

NOT RECURRING

MONTHLY

ANNUALLY

NOT RECURRING

MONTHLY

ANNUALLY

NOT RECURRING

SECTION VIII: WITNESS TO SIGNATURE

(Two witness signatures are required if claimant signed 7A with an "X")

VA FORM 21P-8416, OCT 2023

Page 5

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 Section III of this form.

Month

Day

Year

Specify Name of Child or Other:_____________________________________

6A. (1). WHO NEEDED TO TRAVEL?

VETERAN

SPOUSE

CHILD (Specify)

OTHER (Specify)

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

6A. (3). TOTAL MILES

TRAVELED

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

6A. (5). AMOUNT REIMBURSED FROM ANY SOURCE

(VA Medical Center, etc.)

Month

Day

Year

Specify Name of Child or Other:_____________________________________

6B. (1). WHO NEEDED TO TRAVEL?

VETERAN

SPOUSE

CHILD (Specify)

OTHER (Specify)

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

6B. (3). TOTAL MILES

TRAVELED

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

6B. (5). AMOUNT REIMBURSED FROM ANY SOURCE

(VA Medical Center, etc.)

Month

Day

Year

Specify Name of Child or Other:_____________________________________

6C. (1). WHO NEEDED TO TRAVEL?

VETERAN

SPOUSE

CHILD (Specify)

OTHER (Specify)

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

6C. (3). TOTAL MILES

TRAVELED

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

6C. (5). AMOUNT REIMBURSED FROM ANY SOURCE

(VA Medical Center, etc.)

Specify Name of Child or Other:_____________________________________

6D. (1). WHO NEEDED TO TRAVEL?

VETERAN

SPOUSE

CHILD (Specify)

OTHER (Specify)

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

6D. (3). TOTAL MILES

TRAVELED

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

6D. (5). AMOUNT REIMBURSED FROM ANY SOURCE

(VA Medical Center, 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

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

8C. MAILING ADDRESS OF FIRST WITNESS

8A. PRINTED NAME OF FIRST WITNESS

(NOTE: Only to be used if claimant

signed in 7A using an "X")

8B. SIGNATURE OF FIRST WITNESS (NOTE: Only to be used if claimant

signed in 7A using an "X")

Apt./Unit Number

No. and Street

City 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 to which you are not entitled.

8F. MAILING ADDRESS OF SECOND WITNESS

8D. PRINTED NAME OF SECOND WITNESS

(NOTE: Only to be used if claimant

signed in 7A using an "X")

8E. SIGNATURE OF SECOND WITNESS (NOTE: Only to be used if claimant

signed in 7A using an "X")

Apt./Unit Number

No. and Street

City State/Province

Country

Zip Code/Postal Code

Page 6

VA FORM 21P-8416, OCT 2023

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.

Specify Name of Child or Other:________________________________________

1A. WHOSE EXPENSES WERE PAID?

1C. PROVIDER START AND END DATE (MM/DD/YYYY)

NOTE: If care is ongoing leave end date blank.

START:

END:

VETERAN

SPOUSE

CHILD (Specify)

OTHER (Specify)

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

Average Hours Worked

(Per Week)

Specify Name of Child or Other:________________________________________

2A. WHOSE EXPENSES WERE PAID?

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

NOTE: If care is ongoing leave end date blank.

START:

END:

VETERAN

SPOUSE

CHILD (Specify)

OTHER (Specify)

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

Average Hours Worked

(Per Week)

Specify Name of Child or Other:________________________________________

3A. WHOSE EXPENSES WERE PAID?

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

NOTE: If care is ongoing leave end date blank.

START:

END:

VETERAN

SPOUSE

CHILD (Specify)

OTHER (Specify)

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

Average Hours Worked

(Per Week)

Specify Name of Child or Other:________________________________________

4A. WHOSE EXPENSES WERE PAID?

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

NOTE: If care is ongoing leave end date blank.

START:

END:

VETERAN

SPOUSE

CHILD (Specify)

OTHER (Specify)

4B. NAME OF PROVIDER

4D. AMOUNT PAID MONTHLY

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

Payment Rate

(Per Hour)

$ .00

Average Hours Worked

(Per Week)

Specify Name of Child or Other:________________________________________

5A. WHOSE EXPENSES WERE PAID?

5C. PROVIDER START AND END DATE (MM/DD/YYYY)

NOTE: If care is ongoing leave end date blank.

START:

END:

VETERAN

SPOUSE

CHILD (Specify)

OTHER (Specify)

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

Average Hours Worked

(Per Week)

Specify Name of Child or Other:________________________________________

6A. WHOSE EXPENSES WERE PAID?

6C. PROVIDER START AND END DATE (MM/DD/YYYY)

NOTE: If care is ongoing leave end date blank.

START:

END:

VETERAN

SPOUSE

CHILD (Specify)

OTHER (Specify)

6B. NAME OF PROVIDER

6D. AMOUNT PAID MONTHLY

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

Payment Rate

(Per Hour)

$ .00

Average Hours Worked

(Per Week)

NOTE: If needed, you can complete and submit additional copies of Addendum A.

Page 7

VA FORM 21P-8416, OCT 2023

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 continuing medical expense may result in removal of the medical expense from

the date of receipt of the form.

Specify Name of Child or Other:______________________________________________

1A. WHOSE EXPENSES WERE PAID?

VETERAN

SPOUSE

CHILD (Specify)

OTHER (Specify)

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

1C. FREQUENCY

1D. PAYMENT AMOUNT

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

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

MONTHLY

ANNUALLY

NOT RECURRING

Specify Name of Child or Other:______________________________________________

2A. WHOSE EXPENSES WERE PAID?

VETERAN

SPOUSE

CHILD (Specify)

OTHER (Specify)

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

2C. FREQUENCY

2D. PAYMENT AMOUNT

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

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

MONTHLY

ANNUALLY

NOT RECURRING

Specify Name of Child or Other:______________________________________________

3A. WHOSE EXPENSES WERE PAID?

VETERAN

SPOUSE

CHILD (Specify)

OTHER (Specify)

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

3C. FREQUENCY

3D. PAYMENT AMOUNT

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

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

MONTHLY

ANNUALLY

NOT RECURRING

Specify Name of Child or Other:______________________________________________

4A. WHOSE EXPENSES WERE PAID?

VETERAN

SPOUSE

CHILD (Specify)

OTHER (Specify)

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

4C. FREQUENCY

4D. PAYMENT AMOUNT

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

4F. PURPOSE (Insurance premium, medical supplies, etc.)

MONTHLY

ANNUALLY

NOT RECURRING

Specify Name of Child or Other:______________________________________________

5A. WHOSE EXPENSES WERE PAID?

VETERAN

SPOUSE

CHILD (Specify)

OTHER (Specify)

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

5C. FREQUENCY

5D. PAYMENT AMOUNT

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

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

MONTHLY

ANNUALLY

NOT RECURRING

Specify Name of Child or Other:______________________________________________

6A. WHOSE EXPENSES WERE PAID?

VETERAN

SPOUSE

CHILD (Specify)

OTHER (Specify)

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

6C. FREQUENCY

6D. PAYMENT AMOUNT

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

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

MONTHLY

ANNUALLY

NOT RECURRING

Specify Name of Child or Other:______________________________________________

7A. WHOSE EXPENSES WERE PAID?

VETERAN

SPOUSE

CHILD (Specify)

OTHER (Specify)

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

7C. FREQUENCY

7D. PAYMENT AMOUNT

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

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

MONTHLY

ANNUALLY

NOT RECURRING

NOTE: If needed, you can complete and submit additional copies of Addendum B.

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 Section III of VA Form 21P-8416, Medical Expense Report submitted with this addendum.

Month

Day

Year

Specify Name of Child or Other:_____________________________________

1A. WHO NEEDED TO TRAVEL? (Self, spouse, child, etc.)

VETERAN

SPOUSE

CHILD (Specify)

OTHER (Specify)

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

1C. TOTAL MILES

TRAVELED

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

1E. AMOUNT REIMBURSED FROM ANY SOURCE

(VA Medical Center, etc.)

Month

Day

Year

Specify Name of Child or Other:_____________________________________

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

VETERAN

SPOUSE

CHILD (Specify)

OTHER (Specify)

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

2C. TOTAL MILES

TRAVELED

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

2E. AMOUNT REIMBURSED FROM ANY SOURCE

(VA Medical Center, etc.)

Month

Day

Year

Specify Name of Child or Other:_____________________________________

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

VETERAN

SPOUSE

CHILD (Specify)

OTHER (Specify)

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

3C. TOTAL MILES

TRAVELED

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

3E. AMOUNT REIMBURSED FROM ANY SOURCE

(VA Medical Center, etc.)

Specify Name of Child or Other:_____________________________________

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

VETERAN

SPOUSE

CHILD (Specify)

OTHER (Specify)

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

4C. TOTAL MILES

TRAVELED

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

4E. AMOUNT REIMBURSED FROM ANY SOURCE

(VA Medical Center, etc.)

VA FORM 21P-8416, OCT 2023

Month

Day

Year

Specify Name of Child or Other:_____________________________________

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

VETERAN

SPOUSE

CHILD (Specify)

OTHER (Specify)

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

5C. TOTAL MILES

TRAVELED

5D. DATE TRAVELED (MM/DD/YYYY)

5E. AMOUNT REIMBURSED FROM ANY SOURCE

(VA Medical Center, etc.)

Month

Day

Year

Specify Name of Child or Other:_____________________________________

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

VETERAN

SPOUSE

CHILD (Specify)

OTHER (Specify)

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

6C. TOTAL MILES

TRAVELED

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

6E. AMOUNT REIMBURSED FROM ANY SOURCE

(VA Medical Center, etc.)

Month

Day

Year

Specify Name of Child or Other:_____________________________________

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

VETERAN

SPOUSE

CHILD (Specify)

OTHER (Specify)

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

7C. TOTAL MILES

TRAVELED

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

7E. AMOUNT REIMBURSED FROM ANY SOURCE

(VA Medical Center, etc.)

Specify Name of Child or Other:_____________________________________

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

VETERAN

SPOUSE

CHILD (Specify)

OTHER (Specify)

8B. PROVIDE LOCATION TRAVELED TO (Hospital, clinic, pharmacy, etc.)

8C. TOTAL MILES

TRAVELED

8D. DATE TRAVELED (MM/DD/YYYY)

8E. AMOUNT REIMBURSED FROM ANY SOURCE

(VA Medical Center, etc.)

Page 8

NOTE: If needed, you can complete and submit additional copies of Addendum C.

Month

Day

Year

VA FORM 21P-8416, OCT 2023

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)

5. WHAT IS THE FACILITY TELEPHONE NUMBER?

ZIP Code

City

State/Province

No. &

Street

6. WHAT IS THE MAILING ADDRESS OF THE FACILITY'S ADMINISTRATIVE OFFICE?

7. WHAT IS THE FACILITY'S WEBSITE ADDRESS?

F. AMBULATING WITHIN HOME OR LIVING AREAE. USING THE TOILETD. DRESSING

C. TRANSFERRING IN OR OUT OF BED OR CHAIRB. BATHING/SHOWERINGA. EATING

8. PLEASE SELECT EACH ACTIVITY OF DAILY LIVING (ADL) THAT THE FACILITY IS PROVIDING TO THE CARE RECIPIENT.

9. FOR EACH STATEMENT BELOW PLEASE CHECK THE BOX IF THIS STATEMENT IS TRUE FOR THE FACILITY:

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)

15. DATE SIGNED (MM/DD/YYYY)

International Phone Number (If applicable)

Apt./Unit Number

Country

THE STATE OR COUNTRY REQUIRES THIS FACILITY TO BE LICENSED

THE FACILITY IS LICENSED

THE FACILITY IS RESIDENTIAL

THE FACILITY IS STAFFED 24 HOURS

Page 9

VA FORM 21P-8416, OCT 2023

Page 10

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

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.

WORKSHEET FOR IN-HOME ATTENDANT EXPENSES

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

YES NO

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

4. DO YOU WORK FOR AN AGENCY OR

ORGANIZATION?

(If "NO," skip to question 7)

6. WHAT IS THE AGENCY TELEPHONE NUMBER?5. WHAT IS THE NAME OF THE AGENCY OR ORGANIZATION?

ZIP Code

City

State/Province

No. &

Street

7. WHAT IS YOUR MAILING ADDRESS OR THAT OF YOUR AGENCY'S ADMINISTRATIVE OFFICE?

F. AMBULATING WITHIN HOME OR LIVING AREAE. USING THE TOILETD. DRESSING

C. TRANSFERRING IN OR OUT OF BED OR CHAIRB. BATHING/SHOWERINGA. EATING

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

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

YES NO

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.)

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

PER HOUR

13. PLEASE PROVIDE THE HOURLY CHARGES THE CARE RECIPIENT IS

RESPONSIBLE FOR PAYING.

HOURS PER MONTH

14. PLEASE PROVIDE THE TOTAL HOURS PER MONTH THAT YOU PROVIDE

CARE TO THE CARE RECIPIENT.

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)

16. DATE SIGNED (MM/DD/YYYY)

Apt./Unit Number

Country

A. SHOPPING

D. LAUNDERING

G. HOUSEKEEPING

B. FOOD PREPARATION

E. USING TELEPHONE

H. HANDLING MEDICATIONS

C. NON-MEDICAL TRANSPORTATION

F. MANAGING FINANCES