VA Form 21-2680 Examination for Housebound Status or Permanent Need for Regular Aid and Attendance

What Is VA Form 21-2680?

VA Form 21-2680, Examination for Housebound Status or Permanent Need for Regular Aid and Attendance - also known as the VA aid and attendance form - is a form used to determine whether a veteran or their beneficiary is in need of any assistance or extra monetary payments.

The latest version of the form was released by the Department of Veterans Affairs (VA) in September 2018. A VA Form 21-2680 fillable version is available for digital filing and download below or can be found on the VA website.

The VA pays benefits to veterans aged 65 and over with little or no income and to the beneficiaries who are under 65 but who are permanently or completely disabled. The form is completed by a veteran or beneficiary themselves, a claimant who is related to the veteran or beneficiary, or other relatives of the applicant, however, the form should be signed by an examiner.

VA 21-2680 Form contains information about the claimant: how agile they are, what disease they suffer from, what activities they can perform during the day, whether they can leave home. Based on the provided information, the VA makes a decision on assigning the requested help or payments.

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OMB Control No. 2900-0721
Respondent Burden: 30 minutes
Expiration Date: 09-30-2021
VA DATE STAMP
DO NOT WRITE IN THIS SPACE
EXAMINATION FOR HOUSEBOUND STATUS OR PERMANENT
NEED FOR REGULAR AID AND ATTENDANCE
SECTION I: VETERAN'S IDENTIFICATION INFORMATION
NOTE: You can either complete the form online or by hand. Please print the information requested in ink, neatly and legibly to help process the form.
1. VETERAN/BENEFICARY NAME (First, Middle Initial, Last)
4. DATE OF BIRTH (MM/DD/YYYY)
3. VA FILE NUMBER (If applicable)
2. SOCIAL SECURITY NUMBER
Month
Day
Year
5. VETERAN'S SERVICE NUMBER (If applicable)
6. GENDER
MALE
FEMALE
7. TELEPHONE NUMBER (Include Area Code)
8. PREFERRED E-MAIL ADDRESS (Optional)
(Number and street or rural route, P. O. Box, City, State, ZIP Code and Country)
9. PREFERRED MAILING ADDRESS
No. &
Street
City
Apt./Unit Number
State/Province
Country
ZIP Code/Postal Code
SECTION II: CLAIM INFORMATION
10. CLAIMANT'S NAME (First, Middle Initial, Last)
11. CLAIMANT'S SOCIAL SECURITY NUMBER
12. RELATIONSHIP OF CLAIMANT TO VETERAN
13. BENEFIT YOU ARE APPLYING FOR (Choose One)
Special Monthly Compensation (SMC) - Veterans and surviving spouses or parents who are eligible to receive VA compensation due to a service-
related disability or death and require aid and attendance of another person to perform personal functions required in everyday living such as
bathing, feeding, dressing, attending to the wants of nature, adjusting prosthetic devices, or protecting oneself from the hazards of the daily
environment may be eligible for Special Monthly Compensation. A Veteran or a deceased Veteran's surviving spouse may also be eligible for
Special Monthly Compensation based on being housebound (substantially confined to the immediate premises because of permanent disability).
For a Veteran, the disability causing the need for aid and attendance or housebound status must be related to service. These benefits are paid in
addition to monthly compensation. They are not paid without eligibility to compensation.
Special Monthly Pension (SMP) - Veterans and survivors who are eligible for Veteran's Pension and/or Survivors benefits and require the aid and
attendance of another person in order to perform personal functions required in everyday living, such as bathing, feeding, dressing, attending to the
wants of nature, adjusting prosthetic devices, or protecting him/her from the hazards of his/her daily environment, or are housebound (substantially
confined to his/her immediate premises because of permanent disability), may be eligible for Special Monthly Pension (SMP). This benefit is an
increased monthly amount paid to a Veteran or survivor who is eligible for Veterans Pension or Survivors benefits.
SECTION III: INFORMATION OF EXAMINATION
14. DATE OF EXAMINATION
15. HOME ADDRESS
16A. IS CLAIMANT HOSPITALIZED?
16B. DATE ADMITTED
16C. NAME AND ADDRESS OF HOSPITAL
YES
NO
(If "Yes," complete Items 16B and 16C)
VA FORM
21-2680
EXISTING STOCK OF VA FORM 21-2680, MAY 2015,
SEP 2018
Page 1
WILL BE USED.
OMB Control No. 2900-0721
Respondent Burden: 30 minutes
Expiration Date: 09-30-2021
VA DATE STAMP
DO NOT WRITE IN THIS SPACE
EXAMINATION FOR HOUSEBOUND STATUS OR PERMANENT
NEED FOR REGULAR AID AND ATTENDANCE
SECTION I: VETERAN'S IDENTIFICATION INFORMATION
NOTE: You can either complete the form online or by hand. Please print the information requested in ink, neatly and legibly to help process the form.
1. VETERAN/BENEFICARY NAME (First, Middle Initial, Last)
4. DATE OF BIRTH (MM/DD/YYYY)
3. VA FILE NUMBER (If applicable)
2. SOCIAL SECURITY NUMBER
Month
Day
Year
5. VETERAN'S SERVICE NUMBER (If applicable)
6. GENDER
MALE
FEMALE
7. TELEPHONE NUMBER (Include Area Code)
8. PREFERRED E-MAIL ADDRESS (Optional)
(Number and street or rural route, P. O. Box, City, State, ZIP Code and Country)
9. PREFERRED MAILING ADDRESS
No. &
Street
City
Apt./Unit Number
State/Province
Country
ZIP Code/Postal Code
SECTION II: CLAIM INFORMATION
10. CLAIMANT'S NAME (First, Middle Initial, Last)
11. CLAIMANT'S SOCIAL SECURITY NUMBER
12. RELATIONSHIP OF CLAIMANT TO VETERAN
13. BENEFIT YOU ARE APPLYING FOR (Choose One)
Special Monthly Compensation (SMC) - Veterans and surviving spouses or parents who are eligible to receive VA compensation due to a service-
related disability or death and require aid and attendance of another person to perform personal functions required in everyday living such as
bathing, feeding, dressing, attending to the wants of nature, adjusting prosthetic devices, or protecting oneself from the hazards of the daily
environment may be eligible for Special Monthly Compensation. A Veteran or a deceased Veteran's surviving spouse may also be eligible for
Special Monthly Compensation based on being housebound (substantially confined to the immediate premises because of permanent disability).
For a Veteran, the disability causing the need for aid and attendance or housebound status must be related to service. These benefits are paid in
addition to monthly compensation. They are not paid without eligibility to compensation.
Special Monthly Pension (SMP) - Veterans and survivors who are eligible for Veteran's Pension and/or Survivors benefits and require the aid and
attendance of another person in order to perform personal functions required in everyday living, such as bathing, feeding, dressing, attending to the
wants of nature, adjusting prosthetic devices, or protecting him/her from the hazards of his/her daily environment, or are housebound (substantially
confined to his/her immediate premises because of permanent disability), may be eligible for Special Monthly Pension (SMP). This benefit is an
increased monthly amount paid to a Veteran or survivor who is eligible for Veterans Pension or Survivors benefits.
SECTION III: INFORMATION OF EXAMINATION
14. DATE OF EXAMINATION
15. HOME ADDRESS
16A. IS CLAIMANT HOSPITALIZED?
16B. DATE ADMITTED
16C. NAME AND ADDRESS OF HOSPITAL
YES
NO
(If "Yes," complete Items 16B and 16C)
VA FORM
21-2680
EXISTING STOCK OF VA FORM 21-2680, MAY 2015,
SEP 2018
Page 1
WILL BE USED.
PATIENT/VETERAN'S SOCIAL SECURITY NO.
NOTE: EXAMINER PLEASE READ CAREFULLY
The purpose of this examination is to record manifestations and findings pertinent to the question of whether the claimant is housebound (confined to the
home or immediate premises) or in need of the regular aid and attendance of another person. The report should be in sufficient detail for the VA decision
makers to determine the extent that disease or injury produces physical or mental impairment, that loss of coordination or enfeeblement affects the ability:
to dress and undress; to feed him/herself; to attend to the wants of nature; or keep him/herself ordinarily clean and presentable. Findings should be
recorded to show whether the claimant is blind or bedridden. Whether the claimant seeks housebound or aid and attendance benefits, the report should
reflect how well he/she ambulates, where he/she goes, and what he/she is able to do during a typical day.
17. COMPLETE DIAGNOSIS (Diagnosis needs to equate to the level of assistance described in questions 25 through 39)
18B. WEIGHT
18C. HEIGHT
18A. AGE
ACTUAL: LBS.
ESTIMATED: LBS.
FEET:
INCHES:
19. NUTRITION
20. GAIT
21. BLOOD PRESSURE
22. PULSE RATE
23. RESPIRATORY RATE
24. WHAT DISABILITIES RESTRICT THE LISTED ACTIVITIES/FUNCTIONS?
25. IF THE CLAIMANT IS CONFINED TO BED, INDICATE THE NUMBER OF HOURS IN BED
From 9 PM to 9 AM:
From 9 AM to 9 PM:
26. IS THE CLAIMANT ABLE TO FEED HIM/HERSELF? (If "No," provide explanation)
YES
NO
27. IS CLAIMANT ABLE TO PREPARE OWN MEALS? (If "No," provide explanation)
YES
NO
28. DOES THE CLAIMANT NEED ASSISTANCE IN BATHING AND TENDING TO OTHER HYGIENE NEEDS? (If "Yes," provide explanation)
NO
YES
29B. CORRECTED VISION
29A. IS THE CLAIMANT LEGALLY BLIND? (If "Yes," provide explanation)
LEFT EYE
RIGHT EYE
NO
YES
30. DOES THE CLAIMANT REQUIRE NURSING HOME CARE? (If "Yes," provide explanation)
NO
YES
31. DOES THE CLAIMANT REQUIRE MEDICATION MANAGEMENT? (If "Yes," provide explanation)
YES
NO
32. IN YOUR JUDGMENT, DOES THE VETERAN/CLAIMANT HAVE THE MENTAL CAPACITY TO MANAGE HIS OR HER BENEFIT PAYMENTS, OR IS HE OR SHE ABLE TO
DIRECT SOMEONE TO DO SO? (If "No," provide examples and rationale to support your conclusion.)
YES
NO
VA FORM 21-2680, SEP 2018
Page 2
PATIENT/VETERAN'S SOCIAL SECURITY NO.
33. POSTURE AND GENERAL APPEARANCE (Attach a separate sheet of paper if additional space is needed)
34. DESCRIBE RESTRICTIONS OF EACH UPPER EXTREMITY WITH PARTICULAR REFERENCE TO GRIP, FINE MOVEMENTS, AND ABILITY TO FEED HIM/HERSELF, TO
BUTTON CLOTHING, SHAVE AND ATTEND TO THE NEEDS OF NATURE (Attach a separate sheet of paper if additional space is needed)
35. DESCRIBE RESTRICTIONS OF EACH LOWER EXTREMITY WITH PARTICULAR REFERENCE TO THE EXTENT OF LIMITATION OF MOTION, ATROPHY, AND
CONTRACTURESOR OTHER INTERFERENCE. IF INDICATED, COMMENT SPECIFICALLY ON WEIGHT BEARING, BALANCE AND PROPULSION OF EACH LOWER
EXTREMITY.
36. DESCRIBE RESTRICTION OF THE SPINE, TRUNK AND NECK
37. SET FORTH ALL OTHER PATHOLOGY INCLUDING THE LOSS OF BOWEL OR BLADDER CONTROL OR THE EFFECTS OF ADVANCING AGE, SUCH AS DIZZINESS,
LOSS OF MEMORY OR POOR BALANCE, THAT AFFECTS CLAIMANT'S ABILITY TO PERFORM SELF-CARE, AMBULATE OR TRAVEL BEYOND THE PREMISES OF THE
HOME, OR, IF HOSPITALIZED, BEYOND THE WARD OR CLINICAL AREA. DESCRIBE WHERE THE CLAIMANT GOES AND WHAT HE OR SHE DOES DURING A TYPICAL
DAY.
38. DESCRIBE HOW OFTEN PER DAY OR WEEK AND UNDER WHAT CIRCUMSTANCES THE CLAIMANT IS ABLE TO LEAVE THE HOME OR IMMEDIATE PREMISES
39. ARE AIDS SUCH AS CANES, BRACES, CRUTCHES, OR THE ASSISTANCE OF ANOTHER PERSON REQUIRED FOR LOCOMOTION? (If so, specify and describe
effectiveness in terms of distance that can be traveled, as in Item 32 above)
YES
(If "YES," give distance) (Check
OTHER
1 BLOCK
5 or 6 BLOCKS
1 MILE
applicable box or specify distance)
(Specify distance) _____________________
NO
40C. DATE SIGNED
40A. PRINTED NAME OF EXAMINING PHYSICIAN
40B. SIGNATURE AND TITLE OF EXAMINING PHYSICIAN
41B. TELEPHONE NUMBER OF MEDICAL FACILITY
41A. NAME AND ADDRESS OF MEDICAL FACILITY
(Include Area Code)
PRIVACY ACT NOTICE: The 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. Giving us your
Social Security Number (SSN) account information is mandatory. Applicants are required to provide their SSN under Title 38, U.S.C. 5701(c)(1). The VA will not deny an
individual benefits for refusing to provide his or her SSN unless the disclosure is required by a Federal Statute of law in effect prior to January 1, 1975, and still in effect. The
requested information is considered relevant and necessary to determine maximum benefits provided under the law. The responses you submit are considered confidential (38
U.S.C. 5701). Information that you furnish may be utilized in computer matching programs with other Federal or state agencies for the purpose of determining your eligibility
to receive VA benefits, as well as to collect any amount owed to the United States by virtue of your participation in any benefit program administered by the Department of
Veterans Affairs.
RESPONDENT BURDEN: We need this information to determine your eligibility for aid and attendance or housebound benefits. Title 38, United States Code 1521 (d) and
(e), 1115(1)(e), 1311(c) and (d), 1315(h), 1122, 1541(d)(e), and 1502 (b) and (c) 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 pate
at http://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.
Page 3
VA FORM 21-2680, SEP 2018

Download VA Form 21-2680 Examination for Housebound Status or Permanent Need for Regular Aid and Attendance

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What Is VA Form 21-2680 Used for?

The VA 21-2680 is used to outline the health problems veteran or beneficiary suffers from, their physical state, and their ability to make basic movements. It allows them to request aid and assistance or extra money payments in addition to their pension. The decision about the amount of financial assistance or necessary aid is made according to the information provided.

Veterans or beneficiaries will be provided with aid and assistance if they need the help of another person in order to perform basic daily actions, such as bathing, dressing, feeding themselves, etc. A need to stay in bed due to a disability, or being in a nursing facility due to a mental or physical condition is also considered serious enough for receiving aid.

VA Form 21-2680 Instructions

There are no specific instructions provided on this form. All necessary filing guidelines can be found inside the form.

How To Fill out VA Form 21-2680?

  1. Section I. Identification of the veteran. Box 1. Full name of the veteran. Box 2. Social security number. Box 4. Date of birth. Box 5. Service number. Box 6. Gender. Boxes 7-9. Phone number, email, and post addressed.
  2. Section II. Information about the claimant. The veteran and the claimant can be the same person. Boxes 10 and 11 should contain the name and the claimant's social security number. In Box 12 the relationship to the veteran or beneficiary should be mentioned. In Box 13 the claimant must choose between two options for which benefit they apply. The options are Special Monthly Compensation (SMC) and Special Monthly Pension (SMP). SMC is required for veterans or their relatives who are housebound, while SMP is paid only to veterans or claimants with other diseases.
  3. Section III. Information on physical tests and the physical state of the person in need of help. Box 14. The date of the examination. Box 15. Home address of the veteran or beneficiary. Box 16 requires specification, whether the claimant is in a hospital or not. A positive answer requires the date of admission to the hospital, its name and the location in Boxes 16B and 16C. If the answer is negative, these Boxes should be left blank.
  4. Box 17. Information about the claimant's diagnosis. Information in Box 17 must not contradict the data provided in Boxes 25-39. In Boxes 18A-18C physical characteristics of the claimant are recorded, including weight, both actual and estimated, and height in feet and inches. In Boxes 19-20 information about the nutrition is given. Boxes 21-23 will contain the results of the examination: blood pressure, pulse and respiratory rates. In Box 24 the disabilities preventing the claimant from doing activities listed in questions 26-28 should be listed.
  5. If the claimant has to stay in bed, the hours in bed should be given in Box 25. Boxes 26-28 require basic information on activities, such as feeding, preparing meals, bathing and whether the claimant is able to perform them. If Boxes 26 and 27 contain negative answers and Box 28 is answered positively, an explanation is needed. This can be done on a separate sheet of paper. Boxes 29A and 29B are for providing information about the claimant's sight and whether they are blind or not.
  6. The kind of help the claimant needs and whether they would be able to manage the payments is specified in Boxes 30-32. The answers should be supported by arguments. The posture and appearance of the claimant are described in Box 33. Boxes 34-36 are describing the restrictions to basic actions and movements. All pathologies preventing the claimant from doing these actions are listed in Box 37.
  7. When and under which circumstances the claimant is able to leave home is entered in Box 38. Box 39 is for providing information about whether the claimant requires locomotion assistance. Boxes 40-41 must be completed by the examining physician, providing their name and signature.

Where to Send VA Form 21-2680?

The completed forms should be sent to a local VA regional office.

The Los Angeles Regional Office is responsible for the following regions:

Inyo, Kern, Los Angeles, San Luis Obispo, Santa Barbara, San Bernardino, and Ventura.

Los Angeles Regional Office, Federal Building, 11000 Wilshire Boulevard, Los Angeles, CA 90024

The San Diego Regional Office covers the following counties: Imperial, Orange, Riverside and San Diego.

San Diego Regional Office, 8810 Rio San Diego Drive San Diego, CA 92108

The Reno Regional Office is responsible for the following regions: Alpine, Lassen, Modoc, and Mono.

Reno Regional Office: 5460 Reno Corporate Drive Reno, NV 89511

The Oakland Regional Office covers all remaining counties.

Oakland Regional Office: 1301 Clay Street, Room 1400 North, Oakland, CA 94612

Video Instructions for VA Form 21-2680

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