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Va Form 21 2680

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An Examination for Housebound Status or Permanent Need for Regular Aid and Assistance is a document that a veteran and his or her dependents would use to request aid or assistance. Formally known as VA Form 21-2690, this document would be submitted to the Department of Veterans Affairs to request assistance due to a medical condition. This form will require detailed information about the veteran’s medical history and conditions, all of which must be completed by a licensed medical examiner. In this form, the medical examiner will also be required to list the daily activities that the veteran can do for themselves. These activities may include acts such as the person being able to get dressed or bathe on their own. It is important that the Department has all of the necessary information regarding the veteran’s condition, in detail, so that the most well-informed decision on assistance can be made.

Va Form 21 2680

Related Documents

VA Form 29-4125 › VA Form 10-2850C › VA Form 10-2850A ›

What is a VA Form 21 2680?

This form is used by the United States Department of Veterans Affairs. A VA Form 21-2690 is known as an Examination for Housebound Status or Permanent Need for Regular Aid and Assistance. The form is used by veterans and their dependents who require assistance due to a medical condition. This form is required to submit a claim for aid and assistance from the Department of Veterans Affairs due to the condition.
This veterans benefits form requires detailed information about the claimant. The form has a section about the claimant’s medical history and conditions that must be completed by a licensed medical examiner. The examiner will also need to list the activities that the veteran can do without assistance, such as feeding themselves, getting dressed, and other daily living activities. This information will help the Department of Veterans Affairs determine the claimant’s needs.

Most Common Uses

This form is commonly used by veterans or their dependents who are permanently housebound or have the permanent need for regular aid and assistance due to a medical condition.

Components of a VA Form 21 2680

A VA Form 21-2680 contains the following sections:

  • Veterans Identification Information
  • Claim Information
  • Information of Examination

How to complete a VA Form 21 2680 (Step by Step)

To complete a VA Form 21-2680, you need to provide the following information:

  • Veterans Identification Information
    • Veteran/beneficiary name
    • Social security number
    • VA file number
    • Date of birth
    • Veteran’s service number
    • Gender 
    • Telephone number
    • Preferred email address
    • Preferred mailing address
  • Claim Information
    • Claimant’s name
    • Claimant’s social security number
    • Relationship of claimant to veteran
    • Benefit you are applying for:
      • Special Monthly Compensation (SMC) - For veterans and surviving spouses or parents who are eligible to receive VA compensation due to a service-related disability or death and require regular aid and attendance of another person to perform personal functions such as bathing, feeding, dressing, attending to the wants of nature, adjusting prosthetic devices, or protecting oneself from the hazards of the daily environment. A Veteran or a deceased Veteran's surviving spouse may also be eligible for SMC if housebound (substantially confined to the immediate premises because of permanent disability).
      • Special Monthly Pension (SMP) - Veterans and survivors who are eligible for Veteran's Pension and/or Survivors benefits and require the aid and attendance benefits in order to perform personal functions required in everyday living or are housebound may be eligible for Special Monthly Pension (SMP).
  • Information of Examination
    • Date of examination
    • Home address
    • Whether claimant is hospitalized
    • Date admitted
    • Name and address of hospital
    • Complete diagnosis
    • Age
    • Weight 
    • Height
    • Nutrition 
    • Gait 
    • Blood pressure
    • Pulse rate
    • Respiratory rate
    • What disabilities restrict the listed activities/functions
    • Indicate any hours claimant is confined to bed 
    • Indicate whether the claimant is able to feed self
    • Indicate whether the claimant is able to prepare own meals
    • Indicate whether claimant needs assistance in bathing and tending to other hygiene needs
    • Indicate whether claimant is legally blind
    • Corrected vision in each eye
    • Whether claimant requires nursing home care
    • Whether claimant requires medication management
    • Whether veteran/claimant has mental capacity to manage his or her own benefit payments or is able to direct someone else to do so
    • Posture and general appearance
    • 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 the needs of nature
    • Describe restrictions of each lower extremity with particular reference to the extent of limitation of motion, atrophy, and contracturesor or other interference
    • Describe restriction of the spine, trunk, and neck
    • 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 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 how often per day or week and under what circumstances the claimant is able to leave the home or immediate premises
    • Whether aids such as canes, braces, crutches, or the assistance of another person are necessary for locomotion
    • Name of examining physician
    • Signature and title of examining physician
    • Date signed
    • Name and address of medical facility
    • Telephone number of medical facility

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VA Form 21-2680

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VA Form 29-4125

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Create VA Form 29-4125

VA Form 10-2850C

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Create VA Form 10-2850C

VA Form 10-2850A

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Sample Va Form 21 2680

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Sample Va Form 21 2680

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