#MEDICAL EXPENSE REPORT TEMPLATE VERIFICATION#
#MEDICAL EXPENSE REPORT TEMPLATE CODE#

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

VA cannot conduct or sponsor a collection of information unless a valid OMB control number is displayed. We estimate that you will need an average of 30 minutes to review the instructions, find the information, and complete this form. Title 38, United States Code, allows us to ask for this information. 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.

#MEDICAL EXPENSE REPORT TEMPLATE VERIFICATION#

Information submitted is subject to verification through computer matching programs with other agencies. The responses you submit are considered confidential (38 U.S.C. 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. Refusal to provide your SSN by itself will not result in the denial of benefits. Giving us your SSN account information is voluntary. Providing your SSN will help ensure that your records are properly associated with your claim file. VA uses your SSN to identify your claim file. The requested information is considered relevant and necessary to determine maximum benefits provided under law. Your obligation to respond is required to obtain or retain benefits.

#MEDICAL EXPENSE REPORT TEMPLATE CODE#

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. Generally, a VA-accredited attorney or agent may charge you a fee for assisting in seeking further review of a claim for VA benefits only after VA has issued an initial decision on the claim and the attorney or agent has complied with the applicable power-of-attorney and the fee agreement requirements. Be sure to write your VA file number on any attachments.įEES FOR CLAIMS: Section 5904, Title 38, United States Code (codified in § 14.636, Title 38, Code of Federal Regulations) contains provisions regarding fees that may be charged, allowed, or paid for services provided by a VA-accredited attorney or agent in connection with a proceeding before the Department of Veterans Affairs with respect to a claim for benefits under laws administered by the Department. If you need more space to report expenses, attach a separate sheet of paper with columns corresponding to those on this form.

If you are unable to provide documentation of your claimed medical expenses when VA asks you to do so, your benefits may be retroactively reduced or discontinued. VA may require you to verify the amounts you paid, so keep all receipts or other documentation of payments forĪt least 3 years after we make a decision on your medical expense claim.If you are claiming expenses for an in-home care provider or for assisted living or similar care, you must complete the appropriate worksheet on page 5 or 6 to determine whether VA may deduct all or some of your payments to the provider or facility.We will let you know if we cannot deduct an expense. If you are not sure whether VA can deduct a payment for a particular expense, furnish a complete description of the purpose of the payment.If you are a veteran, VA can deduct allowable expenses paid by either you or your spouse.If you receive reimbursement after you have filed this claim, promptly notify the VA office handling your claim. Do not include any expenses for which you were or will be reimbursed.Below are examples of expenses you should include, if applicable:Įxpenses related to transportation to a hospital, Report any medical or dental expenses that you paid for yourself or for a relative who is a member of your household (spouse, grandchild, parent, etc.) for which you were not reimbursed and do not expect to be reimbursed. Your out-of-pocket payments for medical and dental expenses may be deductible. Your benefit rate is based on your income. VA may be able to pay you a higher benefit rate if you identify expenses VA can deduct from your income. Landlord (Tenant) Recommendation Letter.

Medical expense report template