Expense Report Form 3Expense Report Form 3Expense Report Form 3
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INSTRUCTIONS FOR MEDICAL EXPENSE REPORT
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
applicable:






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

IMPORTANT NOTES
• Do not include any expenses for which you were reimbursed. If you receive reimbursement after you have filed this
claim, promptly