VA Form 21-2680 Examination for Housebound Status

Submit the completed VA Form 21-2680 to the appropriate Department of Veterans Affairs office. Ensure that all sections are carefully filled out and verified for accuracy. Submission can be done via mail to the address provided on the form or electronically if applicable. It's advisable to keep a copy of the submitted form for your records.

No specific important dates are assigned for 2024 and 2025 as this form is used based on individual need and eligibility.

The primary purpose of VA Form 21-2680 is to evaluate veterans and claimants for housebound status or the need for regular aid and attendance. This evaluation helps in determining eligibility for Special Monthly Compensation or Pension benefits. Accurate completion and submission of this form ensure that applicants receive the support they need based on their specific circumstances.

• 1. VETERAN'S NAME: The full name of the veteran.
• 2. SOCIAL SECURITY NUMBER: The veteran's Social Security Number.
• 3. VA FILE NUMBER: The veteran's VA file number, if applicable.
• 4. DATE OF BIRTH: The veteran's date of birth in MM-DD-YYYY format.
• 5. VETERAN'S SERVICE NUMBER: Veteran's service number, if applicable.
• 6. SEX: The gender of the veteran.
• 7. TELEPHONE NUMBER: The veteran's phone number including area code.
• 8. E-MAIL ADDRESS: Optional email address of the veteran.
• 9. PREFERRED MAILING ADDRESS: The preferred mailing address of the veteran.
• 10. CLAIMANT'S NAME: Full name of the claimant if not the veteran.
• 11. CLAIMANT'S SOCIAL SECURITY NUMBER: Social Security Number of the claimant.
• 12. RELATIONSHIP OF CLAIMANT TO VETERAN: Relationship of the claimant to the veteran.
• 13. CLAIMANT'S HOME ADDRESS: Address of the claimant.
• 14. BENEFIT YOU ARE APPLYING FOR: The specific benefit the claimant is applying for.
• 15. DATE OF EXAMINATION: Date the examination took place.
• 16. IS CLAIMANT HOSPITALIZED: Indication if claimant is hospitalized and related details.
• 17. NAME OF HOSPITAL: Name and address of the hospital if the claimant is hospitalized.
• 18. COMPLETE DIAGNOSIS: Diagnosis details pertinent to aid and attendance or housebound status.
• 19. AGE: Age of the claimant.
• 20. WEIGHT: Weight of the claimant in pounds.
• 21. HEIGHT: Height of the claimant.
• 22. NUTRITION: Nutritional condition of the claimant.
• 23. GAIT: Details about the claimant's gait.
• 24. BLOOD PRESSURE: Claimant's blood pressure readings.
• 25. PULSE RATE: Pulse rate of the claimant.
• 26. RESPIRATORY RATE: Respiratory rate of the claimant.
• 27. WHAT DISABILITIES RESTRICT THE LISTED ACTIVITIES/FUNCTIONS: Disabilities that restrict the veterans daily activities.
• 28. IS THE CLAIMANT ABLE TO FEED HIM/HERSELF: Claimant's ability to feed themselves.
• 29. IS CLAIMANT ABLE TO PREPARE OWN MEALS: Claimant's ability to prepare their own meals.
• 30. DOES THE CLAIMANT NEED ASSISTANCE IN BATHING AND TENDING TO OTHER HYGIENE NEEDS: Details about assistance needed for bathing and hygiene.
• 31. IS THE CLAIMANT LEGALLY BLIND: Indication if the claimant is legally blind and related vision details.
• 32. DOES THE CLAIMANT REQUIRE NURSING HOME CARE: Indication if the claimant requires nursing home care.
• 33. DOES THE CLAIMANT REQUIRE MEDICATION MANAGEMENT: Indication if the claimant requires medication management.
• 34. MENTAL CAPACITY TO MANAGE BENEFIT PAYMENTS: Claimant's mental capacity to manage benefit payments.

Failing to submit this form may result in a delay or denial of benefits.

• Benefits Delay: A delay in processing your benefits application.
• Benefits Denial: Denial of the Special Monthly Compensation or Pension benefits.
• Lack of Support: Not receiving the necessary support for daily living activities.

• 1. Special Monthly Compensation: For veterans with service-related disabilities requiring aid and attendance.
• 2. Special Monthly Pension: For veterans and survivors needing aid and attendance or being housebound.
• 3. Aid and Attendance Evaluation: For claimants who need regular aid and attendance for daily activities.