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

In Section I, enter the veteran/beneficiary's name (first, middle initial, last) in Box 1, the Social Security number in Box 2, the VA file number (if applicable) in Box 3, the veteran's service number (if applicable) in Box 4 and the date of birth (MM/DD/YYYY) in Box 5.

Enter the veteran's Social Security number on each of pages 2, 3 and 4.

In Section II, enter the claimant's name (first, middle initial, last) in Box 6, the claimant's Social Security number in Box 7 and the claimant's date of birth (MM/DD/YYYY) in Box 9.

In Box 8, mark the relationship of the claimant to the veteran: self, parent, spouse or child.

Enter the claimant's mailing address in Box 10: number and street or rural route, P. O. Box, city, state, ZIP code and country.

Enter the telephone number in Box 11 (optional), including the area code, or the international phone number if applicable.

Enter the email address in Box 12 (optional). The check box is for agreeing to receive electronic correspondence from VA in regards to the claim.

In Box 13, choose one benefit: Special Monthly Compensation (SMC) or Special Monthly Pension (SMP).

For Special Monthly Compensation (SMC), a veteran's disability causing the need for aid and attendance or housebound status must be related to service.

Special Monthly Compensation is paid in addition to monthly compensation or Dependency Indemnity Compensation (DIC), and is not paid without eligibility to compensation.

In Box 14A, is the claimant hospitalized? Mark YES or NO. If YES, complete Items 14B, 14C and 14D. If NO, skip to Section V.

Enter the date admitted (MM/DD/YYYY) in Box 14B, the name of the hospital in Box 14C and the address of the hospital in Box 14D.

In Section V, the veteran or claimant certifies that the statements on this form are true and correct to the best of their knowledge and belief.

The veteran or claimant signs in Box 15A (required) and enters the date signed in Box 15B (MM/DD/YYYY).

Section VI is the examination information, and the remainder of the form must be filled out by the examiner.

Enter the date of examination (MM/DD/YYYY) in Box 16.

The purpose of the examination is to record manifestations and findings pertinent to the question of whether the veteran or claimant is housebound (confined to the home or immediate premises) or in need of the regular aid and attendance of another person.

Findings should be recorded to show whether the claimant is blind or bedridden.

In Box 17, provide a complete diagnosis with the most significant symptoms for each condition. The diagnosis needs to equate to the level of assistance described in Items 26 through 37.

In Box 18, describe the disability(ies) considered permanent and totally disabling (A to F).

Enter the age in Box 19A, the weight in Box 19B (actual lbs. or estimated lbs.), the height in Box 19C (feet and inches), the nutrition in Box 20 and the gait in Box 21.

Enter the blood pressure in Box 22, the pulse rate in Box 23 and the respiratory rate in Box 24. In Box 25, write what disabilities restrict the listed activities/functions.

If the patient is confined to bed, indicate the number of hours in bed in Box 26: from 9 PM until 9 AM and from 9 AM until 9 PM.

In Box 27, select all that apply of the activities for which the patient requires assistance: bathing/showering, tending to hygiene needs, eating or self-feeding, transferring in or out of bed/chair, dressing, toileting, ambulating within the home or living area and medication management.

For additional activities (i.e., housekeeping, laundering, meal preparation, etc.), specify the additional activity.

In Box 28A, is the patient legally blind? If YES, provide an explanation. In Box 28B, enter the corrected vision for the left eye and the right eye.

In Box 29, does the patient require nursing home care? Mark YES or NO. If YES, provide an explanation.

In Box 30, mark YES or NO: in your judgment, does the patient have the mental capacity to manage their benefit payments, or are they able to direct someone to do so? If NO, provide the disability(ies) that prevent them from performing this function and any rationale to support your conclusion.

In Box 31, describe the posture and general appearance. In Box 32, describe restrictions of each upper extremity: grip, fine movements, and ability to feed themselves, to button clothing, shave and attend to the needs of nature.

In Box 33, describe restrictions of each lower extremity: 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. In Box 34, describe restriction of the spine, trunk, and neck.

In Box 35, describe 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 the patient's ability to perform self-care, or if hospitalized, beyond the ward or clinical area.

In Box 36, describe how often per day or week and under what circumstances (to include the level of assistance required) the patient is able to leave the home or immediate premises.

In Box 37, are aids such as canes, braces, crutches, or the assistance of another person required for locomotion? Mark YES or NO. If YES, check the applicable box (1 block, 5 or 6 blocks or 1 mile) or specify distance in Other.

In Section VII, the examiner enters the printed name in Box 38 and the title in Box 39.

The examiner signs in Box 40 (required) and enters the date signed in Box 41 (MM/DD/YYYY).

In Section VIII, enter the National Provider Identifier (NPI) number of the examiner in Box 42, the name of the medical facility in Box 43, the address of the medical facility in Box 44 and the telephone number of the medical facility (include area code) in Box 45, or the international phone number if applicable.

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 (SMC). Veterans and survivors who are eligible for Veteran's Pension and/or Survivors benefits and require the aid and attendance of another person, or are housebound (substantially confined to their 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.

The law provides severe penalties (including fine and/or imprisonment) for willfully submitting any statement or evidence of a material fact you know to be false, or for fraudulent receipt of any document you are not entitled to.