VA Form 21P-8416B "Report of Medical, Legal, and Other Expenses Incident to Recovery for Injury or Death"

What Is VA Form 21P-8416B?

VA Form 21P-8416B, Report of Medical, Legal, and Other Expenses Incident to Recovery for Injury or Death is a form published by the Department of Veterans Affairs (VA). It is used by veterans to provide information, in order to determine their eligibility for income-based benefits and the rate payable. This form is used to report received compensations for injury or death.

The latest version of the form was released on March 1, 2018, with all previous editions obsolete. A fillable VA Form 21P-8416B is available for download below.

When a claimant is awarded compensation by another entity or government agency based on a personal injury or death, compensation is considered a countable income for VA purposes. The claimant should keep all receipts or other providing documentation of payments for at least 3 years after VA makes a decision on a medical expense claim.

This form is related to VA Form 21P-8416, Medical Expense Report. The VA 21P-8416 is used to report medical or dental expenses that are not or will not be reimbursed. The reported expenses can be paid to the veteran or a member of their family.

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VA Form 21P-8416B Instructions

The form is distributed without any filling guidelines provided by the VA.

How to Fill out VA Form 21P-8416B?

Instructions for VA Form 21P-8416B are as follows:

  1. Part I (Personal Identification Information) is for the personal information of the veteran and the claimant. Item 1 is for the veteran's full name. The veteran's social security number is entered in Item 2. The VA file number is given in Item 3. Item 4 is for the date of birth. If applicable, the veteran's service number is entered in Item 5. The claimant's full name is entered in Item 6. Item 7 is for the current mailing address, including the ZIP code. Items 8 and 9 are for the claimant's phone number and email address respectively.
  2. Part II (Explanation of Expenses) is a chart designed for listing the claimed expenses. Column A is for naming the purpose of expense, such as Legal Fees, Fees for Expert Witnesses, Medical Expenses Paid Before Date of Recovery, etc. The paid amount is entered in Column B. Column C is for the date of payment. The name of the service provided, such as attorney or doctor, is entered in Column D. Column E is for indicating the organization that paid the compensation.
  3. The second page of the form should contain the veteran's social security number entered on the top of the form. If the space provided on the form is not enough, a separate sheet of paper with columns corresponding to those on the form should be used and attached to the form.
  4. The claimant should sign and date the completed form, certifying that all provided information is true.

Where Do I Send VA Form 21P-8416B?

The form may be presented in person or mailed to the local VA benefits office. The mailing address for the VA Form 21P-8416B can be obtained through the VA website. Submitting a claim through the Veteran's Online Application is not possible, because the VONAPP website is no longer available.

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Download VA Form 21P-8416B "Report of Medical, Legal, and Other Expenses Incident to Recovery for Injury or Death"

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OMB Approved No. 2900-0545
Respondent Burden: 45 Minutes
Expiration Date: 03/31/2021
REPORT OF MEDICAL, LEGAL, AND OTHER EXPENSES INCIDENT
VA DATE STAMP
(DO NOT WRITE IN THIS SPACE)
TO RECOVERY FOR INJURY OR DEATH
INSTRUCTIONS: Read the Privacy Act and Respondent Burden Information on Page 2 before
completing the form.
NOTE: If you or a family member received compensation for injury, illness or death, you must
report the date and amount of the recovery to VA. In most instances, the amount received will be
countable income for VA purposes. However, the amount counted in determining your
entitlement to VA benefits can be reduced by the amount of any unreimbursed expenses incurred
in connection with the recovery. Use this form to report those expenses.
PART I - PERSONAL INDENTIFICATION INFORMATION
NOTE: You can either complete the form online or by hand. Please print information using blue or black ink, neatly, and legibly to help process the form.
1. VETERAN'S NAME (First, Middle Initial, Last)
3. VA FILE NUMBER
2. VETERAN'S SOCIAL SECURITY NUMBER
4. DATE OF BIRTH (MM/DD/YYYY)
5. VETERAN'S SERVICE NUMBER (If applicable)
Month
Day
Year
6. CLAIMANT'S NAME (First, Middle Initial, Last) (If other than veteran)
7. CURRENT MAILING ADDRESS (Number and street or rural route, P.O. Box, City, State, ZIP Code and Country)
No. &
Street
City
Apt./Unit Number
Country
State/Province
ZIP Code/Postal Code
8. TELEPHONE NUMBER (Include Area Code)
9. EMAIL ADDRESS (Optional)
PART II - EXPLANATION OF EXPENSES
10. Report all medical, legal, and other expenses that you or a family member incurred incident to recovery for injury or death.
E. COMPENSATION
A. PURPOSE (Legal Fees, Fees for
C. DATE
D. NAME OF PROVIDER
B. AMOUNT PAID
PAID BY
Expert Witnesses, Medical Expenses
(Doctor, Attorney,
PAID
BY YOU
(RR Retirement Board,
(Mo/Day/Yr)
Consultant, etc.)
Paid Before Date of Recovery, etc.)
Civil Lawsuit, etc.)
VA FORM
SUPERSEDES VA FORM 21P-8416b, MAY 2014,
21P-8416b
Page 1
MAR 2018
WHICH WILL NOT BE USED.
OMB Approved No. 2900-0545
Respondent Burden: 45 Minutes
Expiration Date: 03/31/2021
REPORT OF MEDICAL, LEGAL, AND OTHER EXPENSES INCIDENT
VA DATE STAMP
(DO NOT WRITE IN THIS SPACE)
TO RECOVERY FOR INJURY OR DEATH
INSTRUCTIONS: Read the Privacy Act and Respondent Burden Information on Page 2 before
completing the form.
NOTE: If you or a family member received compensation for injury, illness or death, you must
report the date and amount of the recovery to VA. In most instances, the amount received will be
countable income for VA purposes. However, the amount counted in determining your
entitlement to VA benefits can be reduced by the amount of any unreimbursed expenses incurred
in connection with the recovery. Use this form to report those expenses.
PART I - PERSONAL INDENTIFICATION INFORMATION
NOTE: You can either complete the form online or by hand. Please print information using blue or black ink, neatly, and legibly to help process the form.
1. VETERAN'S NAME (First, Middle Initial, Last)
3. VA FILE NUMBER
2. VETERAN'S SOCIAL SECURITY NUMBER
4. DATE OF BIRTH (MM/DD/YYYY)
5. VETERAN'S SERVICE NUMBER (If applicable)
Month
Day
Year
6. CLAIMANT'S NAME (First, Middle Initial, Last) (If other than veteran)
7. CURRENT MAILING ADDRESS (Number and street or rural route, P.O. Box, City, State, ZIP Code and Country)
No. &
Street
City
Apt./Unit Number
Country
State/Province
ZIP Code/Postal Code
8. TELEPHONE NUMBER (Include Area Code)
9. EMAIL ADDRESS (Optional)
PART II - EXPLANATION OF EXPENSES
10. Report all medical, legal, and other expenses that you or a family member incurred incident to recovery for injury or death.
E. COMPENSATION
A. PURPOSE (Legal Fees, Fees for
C. DATE
D. NAME OF PROVIDER
B. AMOUNT PAID
PAID BY
Expert Witnesses, Medical Expenses
(Doctor, Attorney,
PAID
BY YOU
(RR Retirement Board,
(Mo/Day/Yr)
Consultant, etc.)
Paid Before Date of Recovery, etc.)
Civil Lawsuit, etc.)
VA FORM
SUPERSEDES VA FORM 21P-8416b, MAY 2014,
21P-8416b
Page 1
MAR 2018
WHICH WILL NOT BE USED.
Veteran's SSN
10. Report all medical, legal, and other expenses that you or a family member incurred incident to recovery for injury or death. (Continued)
E. COMPENSATION
A. PURPOSE (Legal Fees, Fees for
C. DATE
D. NAME OF PROVIDER
B. AMOUNT PAID
PAID BY
Expert Witnesses, Medical Expenses
PAID
(Doctor, Attorney,
(RR Retirement Board,
BY YOU
(Mo/Day/Yr)
Consultant, etc.)
Paid Before Date of Recovery, etc.)
Civil Lawsuit, etc.)
I CERTIFY THAT the above information is true.
11. SIGNATURE OF CLAIMANT (Sign in ink)
12. DATE SIGNED
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 and Employment Records - VA, 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 under the 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 eligibility to pension (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 45
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 www.reginfo.gov/public/do/PRAMain. If desired, you can call 1-800-827-1000 to get
information on where to send comments or suggestions about this form.
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VA FORM 21P-8416b, MAR 2018
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