VA FORM 21-2680 - EXAMINATION FOR HOUSEBOUND STATUS
OR PERMANENT NEED FOR REGULAR AID AND ATTENDANCE

 

NOTE: PLEASE FILL IN SECTION I: #’s 1, 2 & 4 - VETERAN NAME'S, SOCIAL SECURITY NUMBER & BIRTH DATE only. If the claimant is a surviving spouse, fill in information in section III: #10 & #11 only (surviving spouse’s name and social security #).

 

Have your doctor address (fill out) SECTION III #14-41 B

 

Remember, you need assistance (of some kind) for 
at least two of the “activities of daily living”
.

 

This would indicate that you need help from a person or apparatus such as a cane, walker, wheelchair, oxygen, etc. with: walking, standing, sitting, transferring, dressing, bathing, toileting, laundry, meal preparation, eating, travel, shopping, remembering appointments or help taking medications or with finances. This help does not have to be rendered daily (although advisable).
 

Be sure to tell your doctor that you need help with two or more of these activities and ask them fill out the form accordingly. Have them write: “needs assistance” anywhere on the form.  It must show that they agree, based on your medical condition, that you need a device or person (other than your spouse) helping you with your disability at least once a month or more. 

NOTE:  It is advised that you wait for this form -
it is too important for you to leave and come back later for! 

 

Furthermore, an examination is not necessary unless your physician deems it necessary.
The VA is only looking for verification of your condition not actual exam results.
It is best to have the physician address form and not his assistant.

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