Va Form 21p-8416 - Medical Expense Report Page 3

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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, FEB 2012

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