Fillable Form VA 21-2680 (2018)

What is VA Form 21-2680?

VA Form 21-2680, Examination for Housebound Status or Permanent Need for Regular Aid and Attendance, is used to document the level of care required by a claimant or a claimant's dependent. This form is used by the United States Department of Veterans Affairs. You may be eligible for this benefit if you get a VA pension and meet at least one of the requirements listed below.

At least one of these must be true:

• You need another person to help you perform daily activities, like bathing, feeding, and dressing, or
• You have to stay in bed—or spend a large portion of the day in bed—because of illness, or
• You are a patient in a nursing home due to the loss of mental or physical abilities related to a disability, or
• Your eyesight is limited (even with glasses or contact lenses you have only 5/200 or less in both eyes; or concentric contraction of the visual field to 5 degrees or less)
• Housebound benefits eligibility
• You may be eligible for this benefit if you get a VA pension and you spend most of your time in your home because of a permanent disability (a disability that doesn’t go away).

Note: You can’t get Aid and Attendance benefits and Housebound benefits at the same time.

How to fill out VA Form 21-2680?

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

SECTION I: VETERAN'S IDENTIFICATION INFORMATION

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

• Select what that applies

7. TELEPHONE NUMBER

• Include Area Code

8. E-MAIL ADDRESS (Optional)

9. PREFERRED MAILING ADDRESS

• Number and street or rural route, P. O. Box, City, State, ZIP Code and Country

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

• Select what applies

13. CLAIMANT'S HOME ADDRESS

• Number and street or rural route, P. O. Box, City, State, ZIP Code and Country

14. BENEFIT YOU ARE APPLYING FOR (Choose One)

• Special Monthly Compensation (SMC)
• Special Monthly Pension (SMP)

SECTION III: INFORMATION OF EXAMINATION

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

16.

a. IS CLAIMANT HOSPITALIZED?

• Select what applies
• If "Yes," complete Items 16B and 16C

b. DATE ADMITTED (MM-DD-YYYY)

17.

a. NAME OF HOSPITAL

b. ADDRESS OF HOSPITAL

c. COMPLETE DIAGNOSIS

• Diagnosis needs to equate to the level of assistance described in questions 25 through 39

18.

a. AGE

b. WEIGHT

• ACTUAL LBS.
• ESTIMATED LBS.

c. HEIGHT

• 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 appropriate circle
• If "No," provide explanation

27. Is the claimant able to prepare their own meals?

• Fill in appropriate circle
• If "No," provide explanation

28. Does the claimant need assistance in bathing and tending to other hygiene needs?

• Fill in appropriate circle
• If "Yes," provide explanation

29.

a. Is the claimant legally blind?

• Fill in appropriate circle
• If "Yes," provide explanation

b. Corrected vision

• Left eye
• Right eye

30. Does the claimant require nursing home care?

• Fill in appropriate circle
• If "Yes," provide explanation

31. Does the claimant require medication management?

• Fill in appropriate circle
• If "Yes," provide explanation

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?

• Fill in appropriate circle
• If "No," provide examples and rationale to support your conclusion

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 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 contractures or other interference. if indicated, comment specifically on weight bearing, balance, and propulsion of each lower extremity.

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

SECTION IV: CERTIFICATION AND SIGNATURE

40.

a. PRINTED NAME OF PHYSICIAN

b. SIGNATURE AND TITLE OF EXAMINING PHYSICIAN

c. DATE SIGNED (MM-DD-YYYY)

41. NATIONAL PROVIDER IDENTIFIER (NPI) NUMBER

42.

a. TELEPHONE NUMBER OF MEDICAL FACILITY

b. NAME OF MEDICAL FACILITY

c. ADDRESS OF MEDICAL FACILITY

Where to file VA Form 21-2680?

Fill out VA Form 21-2680 (Examination for Housebound Status or Permanent Need for Regular Aid and Attendance) and mail it to the VA Pension Management Center (PMC) of your state. You can have your doctor fill out the examination information section.

You can also include with your VA Form 21-2680:

• Other evidence, like a doctor’s report, that shows you need Aid and Attendance or Housebound care
• Details about what you normally do during the day and how you get to places
• Details that help show what kind of illness, injury, or mental or physical disability affects your ability to do things, like take a bath, on your own

If you’re in a nursing home, you’ll also need to fill out a Request for Nursing Home Information in Connection with Claim for Aid and Attendance (VA Form 21-0779).