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3OMB Control No. 2900-0161
Respondent Burden: 30 minutes
FOR VA USE ONLY
~
Department of Veterans Affairs
MEDIICAL 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.
7. FIRST NAME OF CLAIMANT
18.
MIDDLE NAME OF CLAIMANT
19.
LAST NAME OF CLAIMANT
11. STREET ADDRESS OF CLAIMANT
13. CITY
14. STATE
10 SUFFIX NAME OF CLAIMANT
12. APT. NO.
15. ZIP CODE
11. EVENING TELEPHONE NO. OF CLAIMANT (Inclllde Area Code)
10. DAYTIME TELEPHONE NO. OF CLAIMANT (Include Area Code)
9. E-MAIL ADDRESS OF CLAIMANT (Ifapplicabte)
Item 3A is different from tas/ address{umished
10
VA)
8. CHANGE OF ADDRESS (Check box
if
address in
D
5. 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
A. MEDICAL FACILITY TO WHICH
MILES TRAVELED
YOU TRAVELED
(Personal conveyance only)
C. AMOUNT PAID BY YOU
D. DATE PAID
E. FOR WHOM PAID
(Taxi, public transportation jares,
(Month/Day/Year)
(Self, spouse, child)
tolls, parkingjees, etc.)
IMPORTANT: Be sure to sign this form in Item 7A on the reverse side. Unsigned reports will be returned.
~~t~~~
21 P-8416
If'I'HICH WILL NOT BE USED.
SUPERSEDES VA FORM 21-8416, SEP 2011,
(Continued on Reverse)
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