21P-8416

Medical Expense Report

Agency
VA
Revision
October 2023
Fillable fields
517
Pages
10
Official source
VA form page
Checked
October 20, 2026
Fill 21P-8416 online
Page 1 of form 21P-8416

VA Form 21P-8416: Medical Expense Report

VA Form 21P-8416 is the U.S. Department of Veterans Affairs Medical Expense Report. VA's page says to use it to report medical or dental expenses that you have paid for yourself or for a family member living in your household, expenses you weren't reimbursed for and don't expect to be reimbursed for. The instructions explain that your benefit rate is calculated based on your income and that out-of-pocket medical, optical and dental payments may be deductible.

The PDF has 10 pages: two pages of instructions, the report in Sections I to VIII, Addendums A to C for more care, medical and mileage entries, and two worksheets that care providers complete. The instructions say not to send receipts.

VA's page says you can submit your request online instead of filling out and sending the paper form. You can fill out the PDF free in your browser on this page and download the result without an account.

Top of page 1 of VA Form 21P-8416: Medical Expense Report, as printed by VA

What's on VA Form 21P-8416

Sections I and II: Veteran and claimant

The Veteran's name, Social Security number and VA file number, then the claimant's name if different, mailing address, primary telephone number and optional email.

Section III: Reporting period

The date range the expenses were paid in, or the date received by VA for initial applications. The section explains how the effective date is typically set.

Section IV: In-home and facility care

Whose expenses were paid, the provider's name, start and end dates, the amount paid monthly and, for an in-home provider, the hourly rate and average hours worked.

Section V: Other medical expenses

Up to seven entries, each with whose expenses, date paid, frequency as monthly, annually or not recurring, amount, who was paid and the purpose.

Section VI: Mileage

Miles traveled for medical purposes in a privately owned vehicle: who traveled, where to, total miles, the date and any amount reimbursed.

Sections VII and VIII, addendums and worksheets

The certification and signature, witnesses for a signature made with an X, Addendums A to C for more entries, and the two care provider worksheets.

How to complete VA Form 21P-8416

  1. 1

    Set the reporting period

    For an initial application, the form says to report only expenses paid on or after your effective date. If already receiving pension, report by calendar year, or the period a VA letter names.

  2. 2

    List care and medical expenses

    The form says to report a recurring expense on one line, with the start date and a monthly or annual rate, and each non-recurring expense on its own line.

  3. 3

    Add mileage

    Report travel for medical purposes in a privately owned vehicle that took place between the dates in Section III.

  4. 4

    Add addendums and worksheets

    Use Addendums A to C for more entries, as many copies as needed. The form says each in-home or facility care provider completes the matching worksheet.

  5. 5

    Keep your receipts

    The instructions say not to submit receipts, and to keep receipts or other proof of payment for at least 3 years after receiving a decision, since VA may ask you to verify amounts.

  6. 6

    Sign and submit it

    Sign Item 7A and date Item 7B, certifying you have not and will not receive reimbursement for these expenses, then submit it online or send it to VA.

Why fill Form 21P-8416 on indox

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Submitting it and getting help

Online

VA's page says you can submit your request online instead of filling out and sending the paper form.

Mailing address

The form does not print a mailing address. It lists VA's call center at 1-800-827-1000.

Reimbursed later

If you receive reimbursement after filing, the instructions say to promptly notify VA with VA Form 21-4138, Statement in Support of Claim, or by calling 1-800-827-1000.

Help with the form

The instructions point to accredited Veterans Service Officers at https://www.va.gov/vso/, your state office of Veterans Affairs, and accredited attorneys and claims agents, appointed with VA Form 21-22 or 21-22a.

Edition

The OCT 2023 edition supersedes VA Form 21P-8416, DEC 2021. It carries OMB Control No. 2900-0161, with an expiration date of 10/31/2026, and a respondent burden of 30 minutes.

Related forms

Who uses VA Form 21P-8416?

  • Claimants reporting household expenses

    The instructions say it reports medical expenses you paid for yourself or for a relative who is a dependent member of your household, such as a spouse, child, grandchild or parent, that were not reimbursed.

  • Constructive household members

    The form says the expenses can be for a constructive member of the household, such as a spouse in a nursing home or a child away at school.

  • Authorized representatives

    Item 7A is the signature of the claimant or authorized representative. If the claimant signs with an X, Section VIII asks for two witnesses.

  • Facility staff

    The residential care, adult daycare or similar facility worksheet is completed by an administrator or licensed medical professional from that facility.

  • In-home care providers

    The in-home attendant worksheet is completed by the in-home care provider, or by an agency administrator if an agency provides the care.

  • Nursing home residents

    For a nursing home listed under "Nursing homes including rehab services" on Medicare Care Compare, the form asks for VA Form 21-0779 instead of a worksheet.

The form and its worksheets say who fills in each part.

Official sources and the blank

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Questions about Form 21P-8416

What expenses go on VA Form 21P-8416?

The instructions give examples such as hospital expenses, doctor's office fees, dental fees, prescription and non-prescription drugs, vision care, medical insurance premiums, nursing home costs, hearing aids, home health services, medical transportation and the monthly Medicare deduction.

Do I send receipts with the form?

No. The instructions say not to submit receipts, and to keep them for at least 3 years after receiving a decision, because VA may ask you to verify the amounts you paid.

Which dates should I report?

For an initial application, expenses paid on or after your effective date. If you already receive pension, a calendar year. If responding to a VA letter, the period it names. The form says to use separate forms for date ranges beyond a 1-year period.

Can I submit it online?

Yes. VA's page says you can submit your request online instead of filling out and sending the paper form.

What if I get reimbursed after I file?

The instructions say to promptly notify VA by submitting VA Form 21-4138, Statement in Support of Claim, or by contacting the call center at 1-800-827-1000.

Who fills in the care worksheets?

An administrator or licensed medical professional completes the facility worksheet, and the in-home care provider or an agency administrator completes the in-home attendant worksheet. For a nursing home, the form points to VA Form 21-0779.