Fillable Va Form 21p-8416 - Medical Expense Report (Page 2 of 3) in pdf

Va Form 21p-8416 - Medical Expense Report Page 2

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OMB Control No. 2900-0161

Respondent Burden: 30 minutes

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

5. VETERAN'S SOCIAL SECURITY NO.

6. VA FILE NUMBER

7. FIRST NAME OF CLAIMANT

8. MIDDLE NAME OF CLAIMANT

9. LAST NAME OF CLAIMANT

10. SUFFIX 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)

18. CHANGE OF ADDRESS (Check box if address in

19. E-MAIL ADDRESS OF CLAIMANT (If applicable)

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, DEC 2011,

(Continued on Reverse)

FEB 2012

WHICH WILL NOT BE USED.

Va Form 21p-8416 - Medical Expense Report Page 2

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