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36. 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
Hospital Charges, Eyeglasses, Oxygen
Rental, Medical Insurance, etc)
B. AMOUNT PAID
BYYOU
C. DATE PAID
(Month/DaylYear)
D. NAME OF PROVIDER
(Name ofdoctor, dentist,
hospital, lab, etc)
E. FOR WHOM PAID
(Self spouse, child)
MEDICARE (PARTS BAND D)
PRIVATE MEDICAL INSURANCE
CERTIFICATION: I have not and will not receive reimbursement for these expenses. I certify that the above information is true.
7A. SIGNATURE OF CLAIMANT
(Do
NOTprinl)
7B. DATE
PENALTY: The law provides severe penalties which include fine or imprisonment, or both, for the wil'lful 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, DEC 2011
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