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The VA Form 21-2680 is a crucial document for veterans and their families, serving as an examination for determining the need for Housebound status or the necessity of permanent aid and attendance. This form requires detailed information about the veteran's health and capabilities, including diagnoses, mobility, and ability to perform daily functions independently. The goal is to assess whether a veteran is significantly confined to their home due to a permanent disability or requires regular assistance for basic activities such as eating, bathing, and dressing. Filling out this form is the first step toward accessing additional benefits which are above and beyond the standard compensation or pension, making it a vital component in the support system provided to those who have served. It's designed with a respondent burden of just 30 minutes, acknowledging the value of the claimant's time while ensuring that the Veterans Affairs (VA) has all necessary information to make informed decisions regarding the eligibility for these key supplementary benefits. With privacy and confidentiality at its core, the VA Form 21-2680 underscores the commitment to serving veterans’ needs efficiently and respectfully, aiming to improve the quality of life for those who require aid and attendance or are housebound.

Preview - Va 21 2680 Form

OMB Control No. 2900-0721 Respondent Burden: 30 minutes Expiration Date: 09-30-2021

EXAMINATION FOR HOUSEBOUND STATUS OR PERMANENT

NEED FOR REGULAR AID AND ATTENDANCE

IMPORTANT: Please read Privacy Act and Respondent Burden information before completing the form.

VA DATE STAMP

(DO NOT WRITE IN THIS SPACE

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'S NAME (First, Middle Initial, Last)

2. SOCIAL SECURITY NUMBER

3.VA FILE NUMBER (If applicable)

4.DATE OF BIRTH (MM-DD-YYYY)

5. VETERAN'S SERVICE NUMBER (If applicable)

6. SEX

 

7. TELEPHONE NUMBER (Include Area Code)

 

 

 

 

 

 

 

 

 

 

 

MALE

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

FEMALE

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

8.E-MAIL ADDRESS (Optional)

9.PREFERRED MAILING ADDRESS (Number and street or rural route, P. O. Box, City, State, ZIP Code and Country)

No. &

Street

Apt./Unit Number

 

 

 

 

 

 

 

City

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

State/Province

 

 

 

Country

 

 

 

ZIP Code/Postal Code

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

SECTION II: CLAIM INFORMATION

10. CLAIMANT'S NAME (First, Middle Initial, Last) (Complete only if you are not the veteran)

11. CLAIMANT'S SOCIAL SECURITY NUMBER

12. RELATIONSHIP OF CLAIMANT TO VETERAN

SPOUSE SELF

13.CLAIMANT'S HOME ADDRESS No. &

Street

Apt./Unit Number

 

 

 

 

 

 

City

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

State/Province

 

 

 

Country

 

 

 

 

ZIP Code/Postal Code

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

14. 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

 

 

15. DATE OF EXAMINATION (MM-DD-YYYY)

16A. IS CLAIMANT HOSPITALIZED?

 

 

 

 

 

 

16B. DATE ADMITTED (MM-DD-YYYY)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

YES

 

NO (If "Yes," complete Items 16B and 16C)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

17A. NAME OF HOSPITAL

 

 

 

 

 

 

 

 

 

 

 

 

17B. ADDRESS OF HOSPITAL

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

SEP 2018

21-2680

 

Page 1

VA FORM

SUPERSEDES VA FORM 21-2680, MAY 2015.

 

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.

17C. COMPLETE DIAGNOSIS (Diagnosis needs to equate to the level of assistance described in questions 25 through 39)

 

18A. AGE

18B. WEIGHT

 

 

 

 

 

 

 

18C. HEIGHT

 

 

 

 

 

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? (Fill in Circle. If "No," provide explanation)

YES NO

27. IS CLAIMANT ABLE TO PREPARE THEIR OWN MEALS? (Fill in Circle. If "No," provide explanation)

YES NO

28.DOES THE CLAIMANT NEED ASSISTANCE IN BATHING AND TENDING TO OTHER HYGIENE NEEDS? (If "Yes," provide explanation)

YES NO

29A. IS THE CLAIMANT LEGALLY BLIND? (If "Yes," provide explanation)

YES NO

29B. CORRECTED VISION

 

LEFT EYE

 

RIGHT EYE

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

30. DOES THE CLAIMANT REQUIRE NURSING HOME CARE? (If "Yes," provide explanation)

YES NO

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.DESCRIBE POSTURE AND GENERAL APPEARANCE (Attach a separate sheet of paper if additional space is needed)

34.DESCRIBE RESTRICTIONS OF EACH UPPER EXTREMITY WITH PARTICULAR REFERANCE 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 REFERANCE TO THE EXTENT OF LIMITATION OF MOTION, ATROPHY, AND CONTRACTURES OR OTHER INTERFERENCE. IF INDICATED, COMMENT SPECIFICALLY ON WEIGHT BEARING, BALANCE AND PROPULSION OF EACH LOWER EXTREEMITY.

36.DESCRIBE RESTRICTION OF 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 38 above)

YES

NO

(If "YES," give distance) (Check

1 BLOCK

5 OR 6 BLOCKS

1 MILE

OTHER

(Specify distance) _____________________

 

applicable box or specify distance)

SECTION IV: CERTIFICATION AND SIGNATURE

40A. PRINTED NAME OF PHYSICIAN

40B. SIGNATURE AND TITLE OF EXAMINING PHYSICIAN

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

40C. DATE SIGNED (MM-DD-YYYY)

 

41. NATIONAL PROVIDER IDENTIFIER (NPI) NUMBER

 

42A. TELEPHONE NUMBER OF MEDICAL FACILITY

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

42B. NAME OF MEDICAL FACILITY

 

42C. ADDESS OF MEDICAL FACILITY

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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.

PENALTY: The law provides severe penalties which include fine or imprisonment, or both, for the willful submission of any statement of a material fact, knowing it to be false or for the fraudulent acceptance of any payment to which you are not entitled.

VA FORM 21-2680, SEP 2018

Page 3
Download Va 21 2680 PDF Form

Form Data

Fact Name Description
OMB Control No. 2900-0721
Respondent Burden 30 minutes
Expiration Date 09-30-2021
Purpose of the Form To determine eligibility for housebound status or the need for regular aid and attendance
Completion Methods The form can be completed online or by hand in ink
Benefits Applied For Special Monthly Compensation (SMC) and Special Monthly Pension (SMP)
Information Required Veteran's identification, claim information, examination details, and physician’s certification
Privacy Act Notice Information collected is protected under the Privacy Act of 1974 and Title 38, code of Federal Regulations 1.576
Penalty for False Statements Includes fines, imprisonment, or both for willful submission of false statements or fraudulent payment acceptance

Instructions on Utilizing Va 21 2680

To apply for housebound status or the need for regular aid and attendance, one must complete VA Form 21-2680 with accurate and thorough information. The process can be meticulous, but its completion is vital for accessing the benefits designed to support those in need due to service-related conditions. Following a step-by-step guide can assist in ensuring all necessary information is properly conveyed.

Step-by-Step Instructions for Filling Out VA Form 21-2680

  1. Start by reading the Privacy Act and Respondent Burden information at the top of the form to understand the purposes and the privacy rights related to your submission.
  2. Section I - Veteran's Identification Information:
    • Enter the veteran's full name, including first, middle initial, and last.
    • Provide the veteran's Social Security Number and VA File Number (if applicable).
    • Fill in the veteran's Date of Birth, Service Number (if applicable), Sex, and contact information, including telephone number and email address (if desired).
    • Indicate the preferred mailing address in the specified fields.
  3. Section II - Claim Information:
    • If you are not the veteran, enter the claimant’s name, Social Security Number, and relationship to the veteran.
    • Select the benefit you are applying for: Special Monthly Compensation (SMC) or Special Monthly Pension (SMP).
  4. Section III - Information on Examination: It’s important that a physician completes this section. Include the examination date and detailed information about the claimant’s medical condition, nutrition, gait, mental capacity, and any aids used for mobility. If additional space is needed, attach separate sheets with matching headers for continuity.
  5. Indicate whether the claimant is hospitalized, including the name and address of the hospital.
  6. Describe the claimant's daily living abilities, such as feeding themselves, preparing meals, and personal hygiene practices.
  7. Detail any diagnoses and restrictions in mobility or self-care, encapsulating how these affect the claimant's daily activities.
  8. Section IV - Certification and Signature:
    • Have the examining physician print their name and provide their signature, title, and date signed.
    • Enter the National Provider Identifier (NPI) number and the contact information of the medical facility.
  9. Review the entire form to ensure all information is accurate and complete before submission.

Once VA Form 21-2680 is fully completed and signed, it should be submitted to the Department of Veterans Affairs as directed. This form is an essential step in verifying eligibility for additional benefits, which can greatly assist eligible veterans or survivors. Processing times can vary, so it's advisable to reach out to a VA representative if there are any questions or to check on the status of an application. Proper documentation and patience during the process will contribute to a smoother experience in accessing the benefits deserved.

Obtain Answers on Va 21 2680

  1. What is the purpose of VA Form 21-2680?

    The primary purpose of VA Form 21-2680 is to assess whether a veteran requires aid and attendance (A&A) of another person for personal care functions needed for everyday living or is housebound. This encompasses veterans who need assistance with activities such as bathing, feeding, dressing, or who are substantially confined to their premises because of permanent disability. The form helps the Department of Veterans Affairs (VA) determine eligibility for additional compensation or pension benefits based on these needs.

  2. Who needs to complete VA Form 21-2680?

    VA Form 21-2680 should be completed by or on behalf of veterans or surviving spouses who are applying for special monthly compensation (SMC) or special monthly pension (SMP) due to being housebound or in need of regular aid and attendance. Healthcare providers, such as physicians or nurse practitioners, are required to fill out the medical examination section of the form to document the claimant's health status, abilities, and the level of care needed.

  3. How do you obtain and submit VA Form 21-2680?

    You can obtain VA Form 21-2680 by downloading it from the VA's official website or by contacting a VA regional office. After filling out the form either online or by hand, it must be submitted to the VA for processing. It is strongly recommended to complete the form accurately and provide detailed information to support the claim. Applicants can submit the form via mail to the pension management center (PMC) of their state or in person at a VA regional office. Additionally, it is possible to get assistance from accredited representatives, like Veterans Service Organizations (VSOs).

  4. What happens after VA Form 21-2680 is submitted?

    After submission, VA Form 21-2680 will be reviewed by the VA to determine eligibility for the claimed benefits. The process involves verifying the veteran's or claimant's service and medical history, assessing the level of disability or need for aid and attendance/housebound status, and then deciding on the claim. The VA may request additional information or documentation as part of this review. Once the evaluation is complete, the claimant will receive a decision letter from the VA. If approved, the letter will detail the benefits awarded. In case of denial, the letter will explain the reasons and provide information on how to appeal the decision.

Common mistakes

Filling out the VA Form 21-2680 correctly is crucial for veterans or claimants seeking housebound status or the need for regular aid and attendance benefits. However, common mistakes can complicate or delay the processing and approval of these important benefits. Here are six errors to avoid:

  1. Not providing complete identification information: Section I requires detailed veteran identification information. Leaving out or incorrectly filling out the Social Security Number, VA File Number, or other vital details can cause delays.
  2. Selecting the wrong benefit type in Section II: Applicants must choose the correct benefit they are applying for - either Special Monthly Compensation (SMC) or Special Monthly Pension (SMP). Confusion or inaccuracies here can lead to incorrect processing of the application.
  3. Incomplete medical examination details: Section III demands comprehensive medical examination information, including a complete diagnosis. Failing to provide detailed and accurate medical findings can hinder the VA’s ability to determine eligibility.
  4. Omission of daily living capabilities: Questions 25 through 39 explore the claimant’s daily living abilities, such as feeding, bathing, and mobility. Incomplete answers or failure to explain a "No" response can leave out critical information needed for decision-making.
  5. Not utilizing additional space for explanations: Many applicants miss the instruction to attach separate sheets for detailed explanations when space provided in the form is insufficient, especially in sections detailing the claimant’s physical restrictions and daily activities. This results in missing key information that could support the claim.
  6. Incorrect or missing certification: Section IV requires the printed name, signature and title of the examining physician, along with the date signed. Overlooking or incorrectly filling out this certification can invalidate the application.

Ensuring that each part of the form is completed accurately and thoroughly is key to facilitating a smooth evaluation process for the benefits sought. Paying close attention to the guidance provided for each section can significantly impact the outcome of the application.

Documents used along the form

When individuals submit the VA Form 21-2680 for Examination for Housebound Status or Permanent Need for Regular Aid and Attendance, they often need to provide additional documentation to support their claim. Understanding these supplementary forms and documents helps streamline the process, ensuring that claimants can provide thorough evidence for their needs.

  • VA Form 21-527EZ: Application for Pension - This form is used by veterans to apply for pension benefits. It's particularly relevant for those who are also applying for aid and attendance or housebound benefits, as it establishes the baseline pension eligibility.
  • VA Form 21-4142: Authorization and Consent to Release Information to the Department of Veterans Affairs (VA) - This form allows the VA to obtain medical records from private health care providers. These records are often necessary to support a claim for aid and attendance or housebound status.
  • VA Form 21-22: Appointment of Veterans Service Organization as Claimant's Representative - Applicants may wish to have a representative from a Veterans Service Organization (VSO) help them with their claim. This form officially appoints a VSO to act on the veteran's behalf.
  • VA Form 21-0845: Authorization to Disclose Personal Information to a Third Party - This document gives the VA permission to discuss the veteran's claim with specified individuals, such as family members or a legal representative, which can be necessary for those who are housebound or severely disabled.
  • VA Form 21-686c: Declaration of Status of Dependents - Veterans applying for aid and attendance benefits due to a need for regular care might need to provide information on their dependents. This form helps in calculating the correct benefit amount if applicable.

Each of these forms and documents plays a crucial role in the application process for aid and attendance or housebound benefits. They allow the Department of Veterans Affairs to fully understand the applicant's circumstances, medical needs, and financial situation. Accurate and complete documentation ensures that veterans and their families receive the support and benefits they are entitled to.

Similar forms

  • The SSA-16: Application for Social Security Disability Insurance (SSDI) is similar to the VA Form 21-2680 as both forms require detailed medical information to determine eligibility for benefits. Both forms assess the level of assistance or attendance a person requires due to their health conditions.

  • HUD 5380: Certification of Domestic Violence, Dating Violence, Sexual Assault, or Stalking and Alternate Documentation closely resembles the VA Form 21-2680 in that both involve providing sensitive personal information intended to support a specific claim for benefits or protections based on individual circumstances.

  • The VA Form 21-22, Appointment of Veterans Service Organization as Claimant's Representative, shares similarities with VA Form 21-2680 as both are used within the Veterans Affairs system to facilitate claims. While Form 21-2680 assesses a claim for aid and attendance, Form 21-22 relates to representation for processing a variety of veterans' claims.

  • The CMS-40B: Application for Enrollment in Medicare Part B, like the VA Form 21-2680, is designed for individuals seeking to obtain a specific type of health-related benefit. Both forms are intended to gather necessary personal and medical information to determine eligibility.

  • The VA Form 10-10EZ, Application for Health Benefits, similarly collects detailed personal and medical information to determine eligibility for VA health benefits, reflecting the VA Form 21-2680's goal of establishing a veteran's need for regular aid or housebound status.

  • IRS Form 8857: Request for Innocent Spouse Relief, though different in content, follows a similar principle to VA Form 21-2680 by requiring specific personal information and circumstances to assess eligibility for a particular form of relief or benefit.

Dos and Don'ts

Filling out the VA Form 21-2680, which is used to apply for increased pension benefits due to housebound status or the need for regular aid and attendance, requires careful attention to detail. Here are 10 essential do's and don'ts to consider during the process:

Do:
  • Read all instructions thoroughly before beginning to fill out the form.
  • Ensure you have all the necessary information at hand, including medical records and personal identification details.
  • Complete the form online if possible, as this can reduce the risk of errors.
  • Print legibly in ink if you are filling the form by hand.
  • Provide detailed medical documentation to support the claim of needing aid and attendance or being housebound.
  • Use the additional comments section to provide any extra information that can help clarify your situation.
  • Double-check all the information for accuracy before submitting the form.
  • Keep a copy of the completed form and all documents provided for your records.
  • Consult with a VA representative or seek legal advice if you have any doubts.
  • Submit the form before the deadline, if applicable.
Don't:
  • Leave any sections incomplete. If a section does not apply, write “N/A.”
  • Forget to sign and date the form; an unsigned form will not be processed.
  • Ignore the importance of providing a comprehensive medical examination report, as it is critical for the assessment.
  • Use corrections fluid or tape; if you need to correct a mistake, it's better to start over on a new form to ensure readability.
  • Include personal information not specifically requested on the form, as this could violate privacy concerns.
  • Rush through the form without verifying the details of your claims and personal information.
  • Assume that submission of the form guarantees approval; eligibility is determined based on the information and documentation provided.
  • Send the form without checking for the latest version or updates to the process.
  • Overlook the respondent burden statement which provides an estimate of the time it will take to complete the form.
  • Forget to ask for help if needed; VA offices and veteran service organizations can provide assistance.

Misconceptions

When navigating the benefits and forms associated with VA assistance, it's important to have clear and accurate information. Misunderstandings about the VA Form 21-2680, the Examination for Housebound Status or Permanent Need for Regular Aid and Attendance, can lead to delays and issues in accessing deserved benefits. Here are six common misconceptions about the form:

  • It's only for veterans with combat-related injuries: This form is not limited to veterans with combat-related injuries. It's available to any veteran or surviving spouse who meets the medical criteria for housebound status or the need for aid and attendance, regardless of how the disability occurred, as long as it's service-connected.
  • Submission guarantees approval: Filling and submitting VA Form 21-2680 does not guarantee approval. The submitted information undergoes a thorough review by the VA to determine eligibility based on the specific criteria for housebound status or the need for aid and attendance benefits.
  • The process is quick: Completing and submitting the form is an important step, but the evaluation process can be lengthy. Response times vary depending on many factors, including the complexity of the case and the VA's current backlog.
  • Medical documentation is optional: This is incorrect. Detailed medical documentation supporting the claim for housebound status or need for aid and attendance is crucial. Without it, the VA cannot make an informed decision regarding eligibility.
  • The form is only for applying for new benefits: Veterans or their surviving spouses who are already receiving VA benefits but whose condition has worsened or changed can also use VA Form 21-2680 to apply for an increased level of benefits.
  • Assistance in completing the form isn't necessary: While individuals can complete the form on their own, seeking assistance can ensure that it is filled out accurately and thoroughly. Help from a VA accredited representative or a healthcare professional can provide valuable guidance.

Understanding these common misconceptions can help veterans and their families navigate the process of applying for housebound status or the need for regular aid and attendance more effectively. It's always best to seek current, comprehensive guidance directly from the VA or accredited professionals when completing this form.

Key takeaways

Filling out the VA Form 21-2680 is crucial for veterans or their family members seeking benefits due to the need for aid, attendance, or housebound status. Here are key takeaways to guide you through the completion and use of this form:

  • The VA Form 21-2680 is designed to assess a claimant's eligibility for Special Monthly Compensation (SMC) or Special Monthly Pension (SMP) due to a permanent need for regular aid and attendance or housebound status.
  • Completion time is estimated at 30 minutes, emphasizing the importance of gathering all necessary information beforehand to streamline the process.
  • Claimants can fill out the form either online or by hand. If completing by hand, use ink and ensure legibility to facilitate processing.
  • Providing the veteran's Social Security Number is mandatory, as required by Title 38, U.S.C. 5701(c)(1), for the purpose of identifying the claimant's records.
  • The examination section requires detailed information about the claimant's medical condition, daily living capabilities, and the extent of assistance needed, outlining the necessity for a thorough medical evaluation.
  • The form must be completed with accurate and up-to-date medical information, including a complete diagnosis that correlates with the level of assistance described.
  • Special attention is given to the claimant's ability to perform daily activities such as feeding themselves, bathing, dressing, and ambulating, which are critical factors in determining eligibility for the benefits applied for.
  • Legally authorized representatives can complete the form on behalf of the veteran if the veteran is unable to do so due to their physical or mental condition.
  • The form must be signed and certified by a physician, providing a professional medical opinion on the veteran's health status and need for aid, attendance, or housebound benefits.
  • Privacy Act Notice ensures the confidentiality of the information provided, detailing the authorized and routine uses of the data collected on this form.
  • Respondents are reminded of the severe penalties for wilfully submitting false statements, underscoring the importance of accuracy and honesty in completion.

By understanding these key points, claimants can ensure a smoother process in applying for aid and attendance or housebound benefits through the VA Form 21-2680, thereby facilitating accurate and timely assessment of their eligibility.

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