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

5. ITEMIZATION OF MEDICAL EXPENSES (Continued)

D. NAME OF PROVIDER

A. PURPOSE (Physician or Hospital Charges

B. AMOUNT PAID

C. DATE PAID

E. FOR WHOM PAID

(Name of doctor, dentist,

Eyeglasses, Oxygen Rental, Medical Insurance, etc.)

BY YOU

(Mo/Day/Yr)

(Self, spouse, child)

hospital, lab, etc.)

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

6B. EVENING TELEPHONE NO. (Include Area Code)

6A. DAYTIME TELEPHONE NO. (Include Area Code)

7A. SIGNATURE OF CLAIMANT (Do NOT print)

7B. 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.

PRIVACY ACT NOTICE: VA will not disclose information collected on this form to any source other than what has been authorized under the Privacy Act of 1974 or Title

38, code of Federal Regulations 1.576 for routine uses (i.e., civil or criminal law enforcement, congressional communications, epidemiological or research studies, the collection

of money owed to the United States, litigation in which the United States is a party or has an interest, the administration of VA programs and delivery of VA benefits,

verification of identity and status, and personnel administration) as identified in the VA system of records, 58VA21/22/28 Compensation, Pension, Education, and Vocational

Rehabilitation Records - VA, and published in the Federal Register. Your obligation to respond is required to obtain or retain benefits. The requested information is considered

relevant and necessary to determine maximum benefits provided under law. VA uses your SSN to identify your claim file. Providing your SSN will help ensure that your records

are properly associated with your claim file. Giving us your SSN account information is voluntary. Refusal to provide your SSN by itself will not result in the denial of benefits.

VA will not deny an individual benefits for refusing to provide his or her SSN unless the disclosure of the SSN is required by a Federal Statute of law in effect prior to January

1, 1975, and still in effect. The responses you submit are considered confidential (38 U.S.C. 5701). Information submitted is subject to verification through computer matching

programs with other agencies.

RESPONDENT BURDEN: We need this information to determine whether medical expenses you paid may be used to reduce the amount of income we count in determining

eligibility to benefits (38 U.S.C. 1503). Title 38, United States Code, allows us to ask for this information. We estimate that you will need an average of 30 minutes to review

the instructions, find the information, and complete this form. VA cannot conduct or sponsor a collection of information unless a valid OMB control number is displayed. You

are not required to respond to a collection of information if this number is not displayed. Valid OMB control numbers can be located on the OMB Internet Page at

If desired, you can call 1-800-827-1000 to get information on where to send comments or suggestions about

this form.

VA FORM 21-8416, SEP 2008