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

Va Form 21p-8416 - Instructions For Medical Expense Report - 2017 Page 3

21. ITEMIZATION OF MEDICAL EXPENSES

Report medical expenses 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.

A. MEDICAL EXPENSE (Physician or

D. NAME OF PROVIDER

B. AMOUNT PAID

C. DATE PAID

E. FOR WHOM PAID

Hospital Charges, Eyeglasses, Oxygen

(Name of doctor, dentist,

BY YOU

(Month/Day/Year)

(Self, spouse, child)

Rental, Medical Insurance, etc.)

hospital, lab, etc.)

MEDICARE (PART B)

MEDICARE (PART D)

PRIVATE MEDICAL INSURANCE

CERTIFICATION: I have not and will not receive reimbursement for these expenses. I certify that the above information is true.

22A. SIGNATURE OF CLAIMANT (Do NOT print)

22B. DATE

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.

VA FORM 21P-8416, JAN 2017

Va Form 21p-8416 - Instructions For Medical Expense Report - 2017 Page 3