Va Form 21p-8416 - Instructions For Medical Expense Report

Va Form 21p-8416 - Instructions For Medical Expense Report - 2017 Page 2

OMB Control No. 2900-0161

Respondent Burden: 30 minutes

Expiration Date: 01/31/2020

FOR VA USE ONLY

MEDICAL EXPENSE REPORT

1. FIRST NAME OF VETERAN

2. MIDDLE NAME OF VETERAN

3. LAST NAME OF VETERAN

4. SUFFIX NAME OF VETERAN

6. VA FILE NUMBER

5. VETERAN'S SOCIAL SECURITY NO.

10. SUFFIX NAME OF CLAIMANT

7. FIRST NAME OF CLAIMANT

8. MIDDLE NAME OF CLAIMANT

9. LAST NAME OF CLAIMANT

11. STREET ADDRESS OF CLAIMANT

12. APT. NO.

14. STATE

15. ZIP CODE

13. CITY

16. DAYTIME TELEPHONE NO. OF CLAIMANT (Include Area Code)

17. EVENING TELEPHONE NO. OF CLAIMANT (Include Area Code)

19. EMAIL ADDRESS OF CLAIMANT (If applicable)

18. CHANGE OF ADDRESS (Check box if address in Items 11-15 is different from last address furnished to VA)

20. ITEMIZATION OF EXPENSES RELATED TO TRANSPORTATION FOR MEDICAL PURPOSES

Report expenses related to transportation to a hospital, doctor, or other medical facility that you paid between the dates

and

. If no dates appear on this line, refer to the accompanying letter or Eligibility Verification Report for the dates you should report

medical expenses.

NOTE: If you claim miles traveled to a medical facility in a personal conveyance (car, motorcycle, other), VA will calculate the allowable expense

amount based on the current mileage rate (41.5 cents per mile).

B. TOTAL ROUNDTRIP

C. AMOUNT PAID BY YOU

D. DATE PAID

A. MEDICAL FACILITY TO WHICH

E. FOR WHOM PAID

MILES TRAVELED

(Taxi, public transportation fares,

(Month/Day/Year)

YOU TRAVELED

(Self, spouse, child)

(Personal conveyance only)

tolls, parking fees, etc.)

IMPORTANT: Be sure to sign this form in Item 22A on the reverse side. Unsigned reports will be returned.

21P-8416

VA FORM

SUPERSEDES VA FORM 21P-8416, SEP 2014,

(Continued on Reverse)

JAN 2017

WHICH WILL NOT BE USED.

Va Form 21p-8416 - Instructions For Medical Expense Report - 2017 Page 2

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