Spina Bifida Healthcare Benefits Program Application
You are the adult child of a Vietnam veteran (or qualifying Korean War veteran) and you have spina bifida. You are applying for VA health care coverage for your spina-bifida-related care.
Gather before you start
Attach with the form
Section I - Applicant Identification
Blocks 1-5Your name, SSN, DOB, addressPII
The child with spina bifida files this application, even if an adult. If the child is a minor or incapacitated adult, a guardian or parent files on their behalf.
(child's legal name, SSN, DOB, address)
- The veteran parent applying instead of the child - the child is the beneficiary of this program.
Section II - Veteran Parent Information
Blocks 6-10Veteran parent's name, SSN, VA File Number, qualifying servicePII
The veteran parent who served in a qualifying location. Qualifying service: Vietnam (in-country service, Thailand, Korean DMZ during specified periods). VA will verify the parent's service location against DD-214 and service records.
(veteran parent's name, VA file number, service location)
- Not documenting in-country Vietnam service if the DD-214 does not clearly show it - may need unit records or other service documentation.
Section III - Medical Diagnosis
Blocks 11-14Spina bifida diagnosis and documentation
Describe the spina bifida diagnosis (type: myelomeningocele, meningocele, etc.) and attach medical records confirming the diagnosis. The diagnosis must be spina bifida (not spina bifida occulta).
e.g., Myelomeningocele spina bifida diagnosed at birth 1975, confirmed by Dr. Smith; medical records attached.
- Spina bifida occulta does NOT qualify for this program - it covers spina bifida (myelomeningocele and meningocele types).
Section IV - Signature
Blocks 15-16Applicant or guardian signature and datePII
Sign and date. If the child is a minor or incapacitated adult, the guardian signs.
(applicant/guardian signature/date)
- Not also filing VA Form 21-0304 if the veteran parent has not claimed the monetary allowance for their child's spina bifida - two separate programs, both may apply.