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The VA Form 21-2680 serves as a critical document for veterans seeking benefits related to their need for assistance due to disabilities. This form is designed to assess whether an individual requires regular aid and attendance or if they are housebound due to their medical conditions. Completion of the form is essential for evaluating eligibility for Special Monthly Compensation or Special Monthly Pension. Applicants must provide personal identification details, including the veteran’s name, social security number, and service number. The form consists of distinct sections, each requiring detailed information about the claimant's situation, such as hospitalization status, physical limitations, and the ongoing challenges they face in daily activities. Furthermore, healthcare professionals are tasked with conducting examinations and documenting findings, which aid the VA in determining the extent of impairment. The importance of accurately filling out this form cannot be underestimated, as it informs the decision-making process that affects the financial and medical support available to those who have served the nation.

Va 21 2680 Example

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
Get Va 21 2680 PDF Form

Form Characteristics

Fact Name Description
Form Purpose The VA Form 21-2680 is used to determine a veteran's need for aid and attendance or housebound status due to disabilities.
OMB Control Number This form carries the OMB Control Number 2900-0721, which is required for federal forms to identify the information collection.
Estimated Completion Time Respondents can expect to take approximately 30 minutes to complete the form, including reviewing instructions and providing necessary information.
Expiration Date The form is set to expire on September 30, 2021, indicating that updates may be necessary thereafter.
Sections The form contains multiple sections, including veteran identification, claim information, examination details, and certifications.
Eligibility Requirements Eligibility for claiming benefits specified in this form is grounded in Title 38 of the United States Code, which outlines required conditions for aid and attendance.
Privacy Act Notice The form includes a Privacy Act Notice, ensuring that personal information is treated confidentially and used solely for the purpose of determining benefits eligibility.
Claim Types Applicants may be applying for Special Monthly Compensation (SMC) or Special Monthly Pension (SMP) based on their eligibility and need for assistance.
Mandatory Information Providing a Social Security Number (SSN) is mandatory for processing the form, according to Title 38, U.S.C. 5701.

Guidelines on Utilizing Va 21 2680

Filling out the VA Form 21-2680 is a critical step in seeking assistance for housebound status or the need for regular aid and attendance. By completing the form accurately, you are providing essential information that will be reviewed for potential benefits. Gather all necessary personal information, and ensure that you carefully follow each step to avoid delays in processing your claim.

  1. Begin by entering the veteran's name. Write the first name, middle initial, and last name clearly.
  2. Input the veteran's Social Security number.
  3. If applicable, add the VA file number.
  4. Fill in the date of birth in the format MM-DD-YYYY.
  5. If available, include the veteran's service number.
  6. Indicate the sex of the veteran (Male or Female).
  7. Provide a telephone number, including the area code.
  8. Optionally, include an email address.
  9. List the preferred mailing address in full, including city, state, ZIP code, and country.
  10. For Section II, if you're not the veteran, complete the claimant's name, Social Security number, and relationship to the veteran.
  11. Provide the claimant's home address, ensuring all details are accurate.
  12. Choose the benefit type you are applying for: Special Monthly Compensation (SMC) or Special Monthly Pension (SMP).
  13. In Section III, record the date of the examination.
  14. Indicate whether the claimant is hospitalized. If yes, provide the admission date.
  15. Fill in the name and address of the hospital, if applicable.
  16. Complete the diagnosis and relevant medical details regarding the claimant's conditions and impairments.
  17. Record the claimant's age, weight (actual and estimated), and height.
  18. Include details on nutrition, gait, blood pressure, pulse rate, and respiratory rate.
  19. Provide information regarding activities the claimant is restricted from, such as feeding themselves or bathing.
  20. If the claimant is confined to bed, note the duration of time spent in bed.
  21. Confirm whether the claimant can feed themselves, prepare meals, or requires assistance with hygiene needs. Provide explanations if they cannot.
  22. Indicate if the claimant is legally blind and provide corrected vision details if applicable.
  23. Clarify if nursing home care or medication management is required and explain if so.
  24. Assess and indicate the mental capacity of the claimant to manage their benefits.
  25. Describe the claimant's posture, general appearance, and any limitations affecting daily activities.
  26. If necessary, provide detailed explanations of any restrictions with upper and lower extremities, spine, trunk, neck, and overall health issues that affect self-care and mobility.
  27. Note how often the claimant can leave the home, including circumstances and distance they can travel if using assistive devices.
  28. In Section IV, have the examining physician print their name, sign, and date the form.
  29. Lastly, provide the physician's National Provider Identifier (NPI) number and contact information of the medical facility.

What You Should Know About This Form

What is the VA Form 21-2680 used for?

The VA Form 21-2680 is designed to help determine whether a veteran is eligible for benefits based on a need for aid and attendance or if they are housebound. These benefits are available for veterans who require assistance with daily activities due to a service-related disability. This form captures important information about the veteran’s health status and functional abilities, helping the VA make informed decisions about the level of support needed.

Who needs to fill out the VA Form 21-2680?

Veterans applying for Special Monthly Compensation (SMC) or Special Monthly Pension (SMP) benefits will need to complete this form. If a veteran is unable to fill it out themselves, a claimant (like a spouse or guardian) may complete the form on their behalf. The claimant’s relationship to the veteran must be clearly indicated on the form.

What information is required to complete the VA Form 21-2680?

Basic identification information for the veteran is needed, including their name, social security number, and date of birth. Additionally, the form requires details about the claimant if they are different from the veteran. It's also essential to provide information about the veteran's current health status, daily living capabilities, and any assistance they may require. The form asks for both medical assessment details and personal observations regarding the veteran's ability to manage daily activities.

How long does it take to complete the VA Form 21-2680?

On average, it will take about 30 minutes to go through the instructions, gather relevant information, and fill out the form. It’s important to be thorough and accurate, as the information provided impacts the evaluation of benefits. Taking the time to ensure everything is filled out correctly can help avoid delays in processing.

Where do I submit the VA Form 21-2680 once completed?

The completed VA Form 21-2680 should be submitted to the appropriate Veterans Affairs regional office. It is crucial to check your local VA office’s submission guidelines to ensure that it’s sent to the right place. You can find contact details and additional resources on the official VA website if you need further assistance.

Common mistakes

Filling out the VA Form 21-2680 requires careful attention to detail. One common mistake individuals make is providing incomplete information in the Veteran's identification information. Each section must be fully filled out, particularly items such as the Veteran's name and Social Security number. Omissions can delay processing and lead to potential denial of benefits.

Another frequent error occurs when individuals fail to sign the form. The absence of a signature in the certification and signature section can cause significant processing delays. A signature verifies that the information provided is accurate and truthful, and without it, the application cannot proceed.

Some people neglect to read the instructions thoroughly before beginning to fill out the form. This leads to misunderstandings about what information is necessary and how to present it. Reading the Privacy Act and other instructions can clarify the requirements and ensure that everything is completed correctly.

Additionally, failing to indicate the claimant's relationship to the Veteran can create confusion. It is essential to specify whether the claimant is the Veteran, spouse, or another relative. This information helps the VA understand who is applying for which benefits.

Another oversight is not properly documenting experiences related to the claimant’s need for aid and attendance. Providing vague or incomplete explanations for inquiries such as the ability to bathe, dress, or prepare meals can limit the effectiveness of the application. Clear and detailed responses are crucial for conveying the level of support required.

Furthermore, using incorrect dates in the examination information section is a problem many individuals encounter. Noting wrong dates can lead to misinterpretation of the medical circumstances surrounding the claim. It's essential to accurately fill in dates related to hospitalization and the examination.

Many applicants also make the mistake of not providing a complete address for the medical facility. A missing or incorrect address can hinder communication between the VA and the medical provider. Ensuring that all contact details are current and correct is vital.

Lastly, individuals often forget to include additional documentation that may support the claim. Attachments and medical reports can provide necessary context and evidence for the information listed within the form. Submitting these additional items can enhance the request and demonstrate the claim's validity.

Documents used along the form

The VA Form 21-2680 is essential for veterans seeking benefits related to aid and attendance or housebound status. However, several other forms and documents are frequently used in conjunction with it. Each document serves a unique purpose in supporting the veteran's claim for additional benefits or assistance. Below is a list of these important forms and documents.

  • VA Form 21-526EZ: This form is used to apply for disability compensation and related benefits. It asks for information about the veteran's service, medical conditions, and the benefits they are seeking.
  • VA Form 21-534EZ: This is a simplified application form for survivors' benefits. It allows surviving spouses or children to claim benefits from a deceased veteran’s service.
  • VA Form 21-4142: This form requests authorization to obtain health care information from private medical facilities. It helps the VA gather pertinent medical records to support the veteran's claim.
  • VA Form 21-22: This is the Appointment of Veterans Service Organization as Claimant's Representative form. Veterans use it to appoint a veterans service organization to assist with their claims.
  • VA Form 21-4142a: Similar to the 21-4142, this form is for authorizing the release of medical records but can be used specifically for records of injury or illness related to the claim.
  • VA Form 21-8940: This form is used to apply for a total disability based on individual unemployability (TDIU). It helps veterans assert that their service-connected disabilities prevent them from retaining gainful employment.
  • VA Form 20-0995: This is a supplemental claim form that allows veterans to submit new and relevant evidence for a previously denied claim. It supports the process of appealing decisions made by the VA.

These forms and documents collectively facilitate access to benefits and ensure that veterans receive the assistance they deserve. Understanding each form's role can simplify the claims process and enhance veterans' support systems.

Similar forms

The VA Form 21-2680 is specifically designed to assess a veteran's need for aid and attendance or housebound benefits. Similar documents also serve to establish eligibility for various benefits related to veteran status. Here are ten documents that share similarities with the VA Form 21-2680:

  • VA Form 21-526EZ: This form allows veterans to apply for disability compensation. Like the 21-2680, it requires detailed personal and service information to determine eligibility for benefits.
  • VA Form 21-555: A claim for death benefits. This form needs information about the veteran's service and the claimant's relationship, much like how the 21-2680 focuses on dependency and care necessities.
  • VA Form 21-4142: Used for the authorization and consent to release medical records. This document facilitates access to relevant medical information, paralleling the need for health assessments in the aid and attendance process.
  • VA Form 21-530: This is specifically for burial benefits. Similar to the 21-2680, it requires information about the veteran's service and establishes the need for benefits based on specific circumstances.
  • VA Form 21-674: This form applies for dependent children of veterans. It focuses on care and financial needs, akin to the assessments made on the 21-2680 form concerning a veteran’s dependence on aid.
  • VA Form 21-0845: Used for the release of information to a third party. This form allows family members or caregivers to assist in the benefits process, similar to how the 21-2680 recognizes claimants and their roles.
  • VA Form 29-4125: This form is related to veterans' life insurance. It similarly collects personal and medical information to determine eligibility based on the veteran's needs and circumstances.
  • VA Form 21-8416: For reporting additional medical expenses for pension purposes. Like the 21-2680, it aims to capture essential health information to evaluate eligibility for increased benefits.
  • VA Form 21-0779: This form requests a special monthly pension for veterans in need of regular aid and attendance. Both forms require thorough documentation to confirm a claim for assistance.
  • VA Form 21-0966: Used for submitting a claim for supplemental benefits. This document outlines the financial and care needs of veterans, similar to the evaluations performed for the 21-2680.

Dos and Don'ts

When filling out the VA Form 21-2680, there are several important guidelines to follow to ensure accurate and efficient processing. The following lists outline essential dos and don'ts:

  • Do read the Privacy Act and Respondent Burden information carefully before starting the form.
  • Do print all information neatly and legibly in ink if completing the form by hand.
  • Do include the veteran's full name and relevant identification numbers.
  • Do accurately specify the benefit being applied for—whether Special Monthly Compensation or Special Monthly Pension.
  • Do provide complete and detailed information about the claimant’s health status and daily activities.
  • Do ensure that all dates are filled out in the correct MM-DD-YYYY format.
  • Do follow up on any sections that require additional explanations or comments.
  • Do check your work for any errors or omissions before submission.
  • Do keep a copy of the completed form for your records.
  • Do submit the form to the appropriate VA address based on your location or instructions.
  • Don't leave any required fields blank; incomplete information can delay processing.
  • Don't use pencil or any writing tools that could result in unclear printing.
  • Don't provide false information or omit significant details, as this can lead to serious consequences.
  • Don't forget to sign and date the form before submission.
  • Don't submit the form without double-checking that all necessary attachments or documentation are included.
  • Don't ignore the specific instructions for documenting medical information and the claimant’s condition.
  • Don't wait until the last minute to submit; aims for timely completion to avoid any issues.
  • Don't presume the VA knows the details of your case; include all relevant explanations.
  • Don't forget to review the expiration date of the form to ensure it is still valid.
  • Don't assume all benefits require the same information; verify requirements for each specific benefit type.

Misconceptions

  • Misconception 1: The VA 21-2680 form is only for veterans who are bedridden.

    • This form is designed for veterans who may need assistance due to various disabilities, not just those confined to bed. It caters to a wide range of needs, including those who may be housebound or require assistance in daily activities.

  • Misconception 2: Completing the VA 21-2680 form is too complicated.

    • While forms can seem overwhelming at first, the VA 21-2680 is structured to guide you through the process. Clear instructions are provided, allowing you to fill it out either online or by hand.

  • Misconception 3: Only the veteran can fill out the form.

    • In fact, the form can also be completed by a claimant who is related to the veteran, such as a spouse or child. This ensures that support is available to those who may have difficulty completing it themselves.

  • Misconception 4: Submitting the VA 21-2680 form guarantees that benefits will be awarded.

    • Submitting the form is just one part of the process. Eligibility for aid and attendance or housebound benefits depends on meeting specific criteria regarding service-related disabilities.

  • Misconception 5: The examination for this form is not essential.

    • The examination is a crucial step in the process. It provides necessary details about the veteran's physical or mental impairments, which are vital for the VA's decision-making regarding benefits.

Key takeaways

The VA Form 21-2680 is a crucial document for veterans seeking special monthly compensation or pension based on housebound status or the need for aid and attendance. Here are some key takeaways for filling out and using this form:

  • Purpose of the Form: The form assesses whether a veteran is housebound or requires regular assistance due to physical or mental impairments.
  • Identification Information: Accurate identification details are essential. This includes the veteran's name, Social Security number, and VA file number.
  • Claimant Information: If the claimant is not the veteran, providing complete information about the claimant is necessary, including their relationship to the veteran.
  • Benefit Selection: Claimants must specify whether they are applying for Special Monthly Compensation (SMC) or Special Monthly Pension (SMP). Understanding eligibility criteria for each benefit is important.
  • Examination Details: The form requires a thorough examination report from a physician, detailing physical and mental capabilities, mobility, and daily living activities.
  • Assistance Requirements: Clear answers about the need for assistance in daily tasks such as feeding, bathing, and hygiene are crucial for eligibility assessment.
  • Frequency of Home Visits: Claimants must describe how often they leave home and the conditions under which they are able to do so.
  • Documentation: It is advisable to attach additional sheets if more space is needed for detailed responses, especially regarding mobility restrictions and daily routines.
  • Compliance and Confidentiality: Always read the Privacy Act notice. The information provided is confidential and used solely for determining eligibility for benefits.

Completing the VA Form 21-2680 accurately and thoroughly can significantly impact the outcome of a claim, making attention to detail imperative throughout the process.

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