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Expense Report Form 3

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Expense Report Form 3
Expense Report Form 3
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 Records
- VA, and published in the Federal Register. Your obligation to respond is required to obtain or retain benefits. The requested information is
considered relevant and necessary to determine maximum benefits provided under law. VA uses your SSN to identify your claim file. Providing your
SSN will help ensure that your records are properly associated with your claim file. Giving us your SSN account information is voluntary. Refusal to
provide your SSN by itself will not result in the denial of benefits. 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. The responses you submit
are considered confidential (38 U.S.C. 5701). Information submitted is subject to verification through computer matching programs with other
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. 1503). Title 38, United States Code, 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 Page at 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.
FEB 2012
VA may be able to pay you at a higher rate if you identify expenses VA considers allowable. Medical and dental
expenses paid by you may be deductible from the income VA counts when determining your benefit entitlement.
In Items 20 and 21 below, identify any medical or dental expenses that you paid for a member of your household (self,
spouse, child, etc.) for which you were not reimbursed. Below are examples of expenses you should include, if
• Hospital expenses
• Doctor's office fees
• Dental fees
• Prescription/non-prescription drug costs
• Vision care costs
• Medical insurance premiums
• Monthly Medicare deduction
• Nursing home costs
• Hearing aid costs
• Dental fees
• Home health service expenses
• Expenses related to transportation to a hospital,
doctor, or other medical facility
• Do not include any expenses for which you were reimbursed. If you receive reimbursement after you have filed this
claim, promptly notify the VA office handling your claim.
• If you are not sure whether a particular expense can be allowed, furnish a complete description of the purposes of the
payment. We will let you know if an expense cannot be allowed.
• You may be asked to verify the amounts you actually paid, so keep all receipts or other documentation of payments for
at lease 3 years after we make a decision on your medical expense claim. If you are unable to provide documentation of
the claimed medical expenses when asked to do so by VA, your benefits may be retroactively reduced or terminated.
• If more space is needed to report expenses, attach a separate sheet of paper with columns corresponding to those on this
form. Be sure to write your VA file number on any attachments.
Expense Report Form 3