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The VA Form 10-10EZ is an essential document for veterans seeking to enroll in the VA health care system. By filling out this form, veterans can provide the necessary information to determine their eligibility for a range of medical benefits. Completing the form typically takes about 30 minutes and requires veterans to gather personal details, military service information, and health insurance coverage. Sections one through three must be completed by all veterans, setting the foundation for the application. If a veteran has not previously enrolled or received benefits, they are encouraged to attach discharge papers, like a DD-214, which can expedite the process. While financial disclosure is only mandatory for certain veterans, not providing this information may affect access to specific benefits. Additional sections pertain to dependents, employment information, and previous income, aiding the VA in assessing the complete context of each applicant's situation. As the application requires signatures and supporting documents, ensuring accurate and thorough submission is crucial for a successful enrollment process.

Va 10 10Ez Example

INSTRUCTIONS FOR COMPLETING ENROLLMENT

APPLICATION FOR HEALTH BENEFITS

Please Read Before You Start . . . What is VA Form 10-10EZ used for?

For Veterans to apply for enrollment in the VA health care system. The information provided on this form will be used by VA to determine your eligibility for medical benefits and on average will take 30 minutes to complete. This includes the time it will take to read instructions, gather the necessary facts and fill out the form.

Where can I get help filling out the form and if I have questions?

You may use ANY of the following to request assistance:

•Ask VA to help you fill out the form by calling us at 1-877-222-VETS (8387).

•Go to www.va.gov/health-care for information about VA health benefits.

•Contact the Enrollment Coordinator at your local VA health care facility.

•Contact a National or State Veterans Service Organization.

Definitions of terms used on this form:

•SERVICE-CONNECTED (SC): A VA determination that an illness or injury was incurred or aggravated in the line of duty, in the active military, naval or air service.

•COMPENSABLE: A VA determination that a service-connected disability is severe enough to warrant monetary compensation.

•NONCOMPENSABLE: A VA determination that a service-connected disability is not severe enough to warrant monetary compensation.

•NONSERVICE-CONNECTED (NSC): A Veteran who does not have a VA determined service-related condition.

Getting Started: ALL VETERANS MUST COMPLETE SECTIONS I - III.

Directions for Sections I - III:

Section I - General Information: Answer all questions.

Section II - Military Service Information: If you are not currently receiving benefits from VA, you may attach a copy of your discharge or separation papers from the military (such as DD-214 or, for WWII Veterans, a "WD" Form), with your signed application to expedite processing of your application. If you are currently receiving benefits from VA, we will cross-reference your information with VA data.

Section III - Insurance Information: Include information for all health insurance companies that cover you, this includes coverage provided through a spouse or significant other. Bring your insurance cards, Medicare and/or Medicaid card with you to each health care appointment.

Directions for Sections IV-VI:

Financial Disclosure: ONLY NSC AND 0% NONCOMPENSABLE SC VETERANS MUST COMPLETE THIS SECTION TO DETERMINE ELIGIBILITY FOR VA HEALTH CARE ENROLLMENT AND/OR CARE OR SERVICES. Financial Disclosure Requirements Do Not Apply To:

•a former Prisoner of War; or

•those in receipt of a Purple Heart; or

•a recently discharged Combat Veteran; or

•those discharged for a disability incurred or aggravated in the line of duty; or

•those receiving VA SC disability compensation; or

•those receiving VA pension; or

•those in receipt of Medicaid benefits; or

•those who served in Vietnam between January 9, 1962 and May 7, 1975; or

•those who served in SW Asia during the Gulf War between August 2, 1990 and November 11, 1998; or

•those who served at least 30 days at Camp Lejeune between August 1, 1953 and December 31, 1987.

You are not required to disclose your financial information; however, VA is not currently enrolling new applicants who decline to provide their financial information unless they have other qualifying eligibility factors. If a financial assessment is not used to determine your priority for enrollment you may choose not to disclose your information. However, if a financial assessment is used to determine your eligibility for cost-free medication, travel assistance or waiver of the travel deductible, and you do not disclose your financial information, you will not be eligible for these benefits.

Section IV - Dependent Information: Include the following:

•Your spouse even if you did not live together, as long as you contributed support last calendar year.

•Your biological children, adopted children, and stepchildren who are unmarried and under the age of 18, or at least 18 but under 23 and attending high school, college or vocational school (full or part-time), or became permanently unable to support themselves before age 18.

•Child support contributions. Contributions can include tuition or clothing payments or payments of medical bills.

VA FORM

10-10EZ

Complete only the sections that apply to you; sign and date the form.

JUL 2021

HEC PAGE 1 OF 5

Continued ...

Section V - Employment Information:

•

 

•

Veterans Employment Status

Company Address

•

Date of Retirement

•

Company Phone Number

•

Company Name

 

 

Section VI - Previous Calendar Year Gross Annual Income of Veteran, Spouse and Dependent Children Report:

•Gross annual income from employment, except for income from your farm, ranch, property or business. Include your wages, bonuses, tips, severance pay and other accrued benefits and your child's income information if it could have been used to pay your household expenses.

•Net income from your farm, ranch, property, or business.

•Other income amounts, including retirement and pension income, Social Security Retirement and Social Security Disability income, compensation benefits such as VA disability, unemployment, Workers and black lung, cash gifts, interest and dividends, including tax exempt earnings and distributions from Individual Retirement Accounts (IRAs) or annuities.

Do Not Report:

Donations from public or private relief, welfare or charitable organizations; Supplemental Security Income (SSI) and need-based payments from a government agency; profit from the occasional sale of property; income tax refunds, reinvested interest on Individual Retirement Accounts (IRAs); scholarships and grants for school attendance; disaster relief payments; reimbursement for casualty loss; loans; Radiation Compensation Exposure Act payments; Agent Orange settlement payments; Alaska Native Claims Settlement Acts Income, payments to foster parent; amounts in joint accounts in banks and similar institutions acquired by reason of death of the other joint owner; Japanese ancestry restitution under Public Law 100-383; cash surrender value of life insurance; lump-sum proceeds of life insurance policy on a Veteran; and payments received under the Medicare transitional assistance program.

Section VII - Previous Calendar Year Deductible Expenses

Report non-reimbursed medical expenses paid by you or your spouse. Include expenses for medical and dental care, drugs, eyeglasses, Medicare, medical insurance premiums and other health care expenses paid by you for dependents and persons for whom you have a legal or moral obligation to support. Do not list expenses if you expect to receive reimbursement from insurance or other sources. Report last illness and burial expenses, e.g., prepaid burial, paid by the Veteran for spouse or dependent(s).

Section VIII - Consent to Copays and to Receive Communications

By submitting this application, you are agreeing to pay the applicable VA copayments for care or services (including urgent care) as required by law. You also agree to receive communications from VA to your supplied email, home phone number, or mobile number. However, providing your email, home phone number, or mobile number is voluntary.

Submitting Your Application

1.You or an individual to whom you have delegated your Power of Attorney must sign and date the form. If you sign with an "X", 2 people you know must witness you as you sign. They must sign the form and print their names. If the form is not signed and dated appropriately, VA will return it for you to complete.

2.Attach any continuation sheets, a copy of supporting materials and your Power of Attorney documents to your application.

Where do I send my application?

Mail the original application and supporting materials to the Health Eligibility Center, 2957 Clairmont Road, Suite 200, Atlanta, GA 30329.

PAPERWORK REDUCTION ACT AND PRIVACY ACT INFORMATION

The Paperwork Reduction Act of 1995 requires us to notify you that this information collection is in accordance with the clearance requirements of Section 3507 of the Paperwork Reduction Act of 1995. We may not conduct or sponsor, and you are not required to respond to, a collection of information unless it displays a valid OMB number. We anticipate that the time expended by all individuals who must complete this form will average 30 minutes. This includes the time it will take to read instructions, gather the necessary facts and fill out the form.

Privacy Act Information: VA is asking you to provide the information on this form under 38 U.S.C. Sections 1705,1710, 1712, and 1722 in order for VA to determine your eligibility for medical benefits. Information you supply may be verified from initial submission forward through a computer-matching program. VA may disclose the information that you put on the form as permitted by law. VA may make a "routine use" disclosure of the information as outlined in the Privacy Act systems of records notices and in accordance with the VHA Notice of Privacy Practices. Providing the requested information is voluntary, but if any or all of the requested information is not provided, it may delay or result in denial of your request for health care benefits. Failure to furnish the information will not have any effect on any other benefits to which you may be entitled. If you provide VA your Social Security Number, VA will use it to administer your VA benefits. VA may also use this information to identify Veterans and persons claiming or receiving VA benefits and their records, and for other purposes authorized or required by law.

VA FORM 10-10EZ, JUL 2021

HEC PAGE 2 OF 5

OMB Control No. 2900-0091 Estimated Burden Avg. 30 min. Expiration Date: 06/30/2024

APPLICATION FOR HEALTH BENEFITS

SECTION I - GENERAL INFORMATION

Federal law provides criminal penalties, including a fine and/or imprisonment for up to 5 years, for concealing a material fact or making a materially false statement. (See 18 U.S.C. 1001)

VA DATE STAMP

(For VHA Use Only)

TYPE OF BENEFIT(S) APPLYING FOR:

ENROLLMENT - VA Medical Benefits Package (Veteran meets and agrees to the enrollment eligibility criteria specified at 38 CFR 17.36) REGISTRATION - VA Health Services (Veterans meets the "Enrollment not required" eligibility criteria specified at 38 CFR 17.37)

1A. VETERAN'S NAME (Last, First, Middle Name)

 

 

 

1B. PREFERRED NAME

 

 

 

2. MOTHER'S MAIDEN NAME

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

3A. BIRTH SEX

3B. SELF-IDENTIFIED GENDER IDENTITY

 

4. ARE YOU SPANISH,

5. WHAT IS YOUR RACE? (You may check more than one.

 

 

MALE

 

 

MALE

 

 

 

FEMALE

 

 

HISPANIC,OR LATINO?

 

Information is required for statistical purposes only.)

 

 

 

 

 

 

 

 

 

 

YES

 

 

ASIAN

 

AMERICAN INDIAN OR ALASKA NATIVE

 

 

 

 

 

 

 

 

 

 

 

 

 

FEMALE

 

 

TRANSMALE/TRANSMAN/FEMALE-TO-MALE

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

NO

 

 

BLACK OR AFRICAN AMERICAN

 

WHITE

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

TRANSFEMALE/TRANSWOMAN/MALE-TO-FEMALE

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

NATIVE HAWAIIAN OR OTHER PACIFIC ISLANDER

 

 

 

 

 

 

 

 

 

 

 

 

 

 

CHOOSE NOT TO ANSWER

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

CHOOSE NOT TO ANSWER

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

6. SOCIAL SECURITY NO.

 

7A. DATE OF BIRTH (mm/dd/yyyy)

7B. PLACE OF BIRTH (City and State)

 

 

 

 

8. RELIGION

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

9A. MAILING ADDRESS (Street)

 

 

9B. CITY

 

 

 

 

9C. STATE

 

9D. ZIP CODE

 

9E.COUNTY

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

9F. HOME TELEPHONE NO. (optional)

 

9G. MOBILE TELEPHONE NO. (optional)

 

 

9H. E-MAIL ADDRESS (optional)

 

 

 

 

 

 

 

 

(Include Area Code)

 

 

 

 

 

(Include Area Code)

 

 

 

 

 

 

 

 

 

 

10A. HOME ADDRESS (Street)

 

 

 

 

 

10B. CITY

 

 

 

 

10C. STATE

 

10D. ZIP CODE

 

10E.COUNTY

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

11. CURRENT MARTIAL STATUS

MARRIED

NEVER MARRIED

SEPARATED

WIDOWED

DIVORCED

12A. NEXT OF KIN NAME

12B. NEXT OF KIN ADDRESS

12C. NEXT OF KIN RELATIONSHIP

12D. NEXT OF KIN TELEPHONE NO.

12E. NEXT OF KIN WORK TELEPHONE NO.

13. DESIGNEE - INDIVIDUAL TO RECEIVE POSSESSION OF YOUR PERSONAL

(Include Area Code)

(Include Area Code)

 

 

PROPERTY LEFT ON PREMISES UNDER VA CONTROL AFTER YOUR

 

 

 

 

DEPARTURE OR AT THE TIME OF DEATH (Note: This does not constitute a

 

 

 

 

will or transfer of title)

 

 

14. WHICH VA MEDICAL CENTER OR OUTPATIENT CLINIC DO YOU PREFER?

15. WOULD YOU LIKE FOR VA TO CONTACT YOU TO SCHEDULE YOUR FIRST

(for listing of facilities visit www.va.gov/find-locations)

 

 

APPOINTMENT?

 

 

 

 

YES

 

NO

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

SECTION II - MILITARY SERVICE INFORMATION

1A. LAST BRANCH OF SERVICE

1B. LAST ENTRY DATE (mm/dd/yyyy)

1C. FUTURE DISCHARGE DATE (mm/dd/yyyy)

1D. LAST DISCHARGE DATE (mm/dd/yyyy)

1E. DISCHARGE TYPE

 

 

 

 

 

 

1F. MILITARY SERVICE NUMBER

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

2. MILITARY HISTORY (Check yes or no)

 

YES NO

 

 

 

 

YES

NO

A. ARE YOU A PURPLE HEART AWARD RECIPIENT?

 

 

 

 

 

 

G. DO YOU HAVE A VA SERVICE-CONNECTED RATING?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

B. ARE YOU A FORMER PRISONER OF WAR?

 

 

 

 

 

 

IF "YES", WHAT IS YOUR RATED PERCENTAGE

 

 

%

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

C. DID YOU SERVE IN A COMBAT THEATER OF OPERATIONS AFTER

 

 

 

 

 

H. DID YOU SERVE IN VIETNAM BETWEEN JANUARY 9, 1962

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

11/11/1998?

 

 

 

 

 

 

AND MAY 7, 1975?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

D. WERE YOU DISCHARGED OR RETIRED FROM MILITARY FOR A

 

 

 

 

 

I. WERE YOU EXPOSED TO RADIATION WHILE IN THE

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

DISABILITY INCURRED IN THE LINE OF DUTY?

 

 

 

 

 

 

MILITARY?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

E. ARE YOU RECEIVING DISABILITY RETIREMENT PAY INSTEAD OF

 

 

 

 

 

J. DID YOU RECEIVE NOSE AND THROAT RADIUM

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

VA COMPENSATION?

 

 

 

 

 

 

TREATMENTS WHILE IN THE MILITARY?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

F. DID YOU SERVE IN SW ASIA DURING THE GULF WAR BETWEEN

 

 

 

 

 

K. DID YOU SERVE ON ACTIVE DUTY AT LEAST 30 DAYS AT

 

 

 

 

 

 

 

 

 

 

 

CAMP LEJEUNE FROM AUGUST 1, 1953 THROUGH

 

 

 

 

 

 

 

 

AUGUST 2, 1990 AND NOVEMBER 11, 1998?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

DECEMBER 31, 1987?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

VA FORM 10-10EZ, JUL 2021

PREVIOUS EDITIONS OF THIS FORM ARE NOT TO BE USED

HEC PAGE 3 OF 5

APPLICATION FOR HEALTH BENEFITS

Continued

VETERAN'S NAME (Last, First, Middle)

SOCIAL SECURITY NUMBER

SECTION III - INSURANCE INFORMATION (Use a separate sheet for additional information)

1. ENTER YOUR HEALTH INSURANCE COMPANY NAME, ADDRESS AND TELEPHONE NUMBER (include coverage through spouse or other person)

2. NAME OF POLICY HOLDER

3. POLICY NUMBER

 

4. GROUP CODE

 

 

 

 

 

5. ARE YOU ELIGIBLE FOR MEDICAID?

6A. ARE YOU ENROLLED IN MEDICARE HOSPITAL INSURANCE PART A?

 

 

(Federal health insurance for low income adults)

 

 

YES

 

NO

 

 

 

 

 

 

 

 

 

 

 

 

 

YES

 

NO

6B. EFFECTIVE DATE (mm/dd/yyyy)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

SECTION IV - DEPENDENT INFORMATION (Use a separate sheet for additional dependents)

1. SPOUSE'S NAME (Last, First, Middle Name)

 

2. CHILD'S NAME (Last, First, Middle Name)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

1A. SPOUSE'S SOCIAL SECURITY NUMBER

 

2A. CHILD'S DATE OF BIRTH (mm/dd/yyyy)

2B. CHILD'S SOCIAL SECURITY NO.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

1B. SPOUSE'S DATE OF

1C. SELF-IDENTIFIED GENDER IDENTITY

2C. DATE CHILD BECAME YOUR DEPENDENT (mm/dd/yyyy)

 

BIRTH (mm/dd/yyyy)

 

 

MALE

 

FEMALE

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

TRANSMALE/TRANSMAN/FEMALE-TO-MALE

2D. CHILD'S RELATIONSHIP TO YOU (Check one)

 

 

 

 

TRANSFEMALE/TRANSWOMAN/MALE-TO-FEMALE

 

 

SON

 

DAUGHTER

 

STEPSON

 

 

STEPDAUGHTER

 

 

 

 

 

 

 

 

 

 

 

 

CHOOSE NOT TO ANSWER

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

2E. WAS CHILD PERMANENTLY AND TOTALLY DISABLED BEFORE THE

 

 

 

 

 

 

1D. DATE OF MARRIAGE (mm/dd/yyyy)

 

 

 

AGE OF 18?

 

 

 

 

 

 

 

YES

NO

1E. SPOUSE'S ADDRESS AND TELEPHONE NUMBER (Street, City, State, ZIP if different from Veteran's)

2F. IF CHILD IS BETWEEN 18 AND 23 YEARS OF AGE, DID CHILD ATTEND SCHOOL LAST CALENDAR YEAR?

YES

NO

2G. EXPENSES PAID BY YOUR DEPENDENT CHILD FOR COLLEGE, VOCATIONAL REHABILITATION OR TRAINING (e.g., tuition, books, materials)

3.IF YOUR SPOUSE OR DEPENDENT CHILD DID NOT LIVE WITH YOU LAST YEAR, DID YOU PROVIDE SUPPORT?

YES

NO

SECTION V - EMPLOYMENT INFORMATION

1A. VETERAN'S EMPLOYMENT STATUS (Check one).

 

 

1B. DATE OF RETIREMENT (mm/dd/yyyy)

 

 

FULL TIME

 

PART TIME

 

NOT EMPLOYED

 

RETIRED

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

1C. COMPANY NAME.

 

 

 

1D. COMPANY ADDRESS

 

 

 

1E. COMPANY PHONE NUMBER

 

 

 

(Complete if employed or retired)

 

 

(Complete if employed or retired - Street, City, State, ZIP )

(Complete if employed or retired)

 

 

 

 

 

 

 

 

 

 

 

(Include area code)

 

 

 

 

 

 

 

 

 

 

 

 

 

SECTION VI - PREVIOUS CALENDAR YEAR GROSS ANNUAL INCOME OF VETERAN, SPOUSE AND DEPENDENT CHILDREN

(Use a separate sheet for additional dependents)

1.GROSS ANNUAL INCOME FROM EMPLOYMENT (wages, bonuses, tips, etc.) EXCLUDING INCOME FROM YOUR FARM, RANCH, PROPERTY OR BUSINESS

2.NET INCOME FROM YOUR FARM, RANCH, PROPERTY OR BUSINESS

3.LIST OTHER INCOME AMOUNTS (e.g., Social Security, compensation, pension, interest, dividends) EXCLUDING WELFARE.

$

$

$

VETERAN

SPOUSE

$

$

$

CHILD 1

$

$

$

SECTION VII - PREVIOUS CALENDAR YEAR DEDUCTIBLE EXPENSES

1.TOTAL NON-REIMBURSED MEDICAL EXPENSES PAID BY YOU OR YOUR SPOUSE (e.g., payments for doctors, dentists, medications, Medicare, health insurance, hospital and nursing home) VA will calculate a deductible and the net medical expenses you may claim.

2.AMOUNT YOU PAID LAST CALENDAR YEAR FOR FUNERAL AND BURIAL EXPENSES (INCLUDING PREPAID BURIAL EXPENSES) FOR YOUR DECEASED SPOUSE OR DEPENDENT CHILD (Also enter spouse or child's information in Section VI.)

3.AMOUNT YOU PAID LAST CALENDAR YEAR FOR YOUR COLLEGE OR VOCATIONAL EDUCATIONAL EXPENSES (e.g., tuition, books, fees, materials) DO NOT LIST YOUR DEPENDENTS' EDUCATIONAL EXPENSES.

$

$

$

VA FORM 10-10EZ, JUL 2021

HEC PAGE 4 OF 5

APPLICATION FOR HEALTH BENEFITS

Continued

VETERAN'S NAME (Last, First, Middle)

SOCIAL SECURITY NUMBER

SECTION VIII - CONSENT TO COPAYS AND TO RECEIVE COMMUNICATIONS

By submitting this application, you are agreeing to pay the applicable VA copayments for care or services (including urgent care) as required by law. You also agree to receive communications from VA to your supplied email, home phone number, or mobile number. However, providing your email, home phone number, or mobile number is voluntary.

ASSIGNMENT OF BENEFITS

I understand that pursuant to 38 U.S.C. Section 1729 and 42 U.S.C. 2651, the Department of Veterans Affairs (VA) is authorized to recover or collect from my health plan (HP) or any other legally responsible third party for the reasonable charges of nonservice-connected VA medical care or services furnished or provided to me. I hereby authorize payment directly to VA from any HP under which I am covered (including coverage provided under my spouse's HP) that is responsible for payment of the charges for my medical care, including benefits otherwise payable to me or my spouse. Furthermore, I hereby assign to the VA any claim I may have against any person or entity who is or may be legally responsible for the payment of the cost of medical services provided to me by the VA. I understand that this assignment shall not limit or prejudice my right to recover for my own benefit any amount in excess of the cost of medical services provided to me by the VA or any other amount to which I may be entitled. I hereby appoint the Attorney General of the United States and the Secretary of Veterans' Affairs and their designees as my Attorneys-in-fact to take all necessary and appropriate actions in order to recover and receive all or part of the amount herein assigned. I hereby authorize the VA to disclose, to my attorney and to any third party or administrative agency who may be responsible for payment of the cost of medical services provided to me, information from my medical records as necessary to verify my claim. Further, I hereby authorize any such third party or administrative agency to disclose to the VA any information regarding my claim.

ALL APPLICANTS MUST SIGN AND DATE THIS FORM. REFER TO INSTRUCTIONS WHICH DEFINE WHO CAN SIGN ON BEHALF OF THE VETERAN.

SIGNATURE OF APPLICANT

 

DATE (mm/dd/yyyy)

(Sign in ink)

 

 

 

VA FORM 10-10EZ, JUL 2021

HEC PAGE 5 OF 5
Get Va 10 10Ez PDF Form

Form Characteristics

Fact Title Fact Description
Purpose of VA Form 10-10EZ This form allows Veterans to apply for enrollment in the VA health care system.
Completion Time On average, it takes about 30 minutes to complete the form, including reading instructions and gathering necessary information.
Financial Disclosure Requirements Only Non-Service Connected Veterans and those with a 0% Non-Compensable rating must complete financial disclosure to determine eligibility.
Contact for Assistance Veterans can seek help by calling 1-877-222-VETS, visiting the VA website, or contacting local Veterans Service Organizations.
Governing Laws This form operates under 38 USC Sections 1705, 1710, 1712, and 1722, which guide the enrollment and benefits processes for Veterans.

Guidelines on Utilizing Va 10 10Ez

Filling out the VA Form 10-10EZ is an important step for Veterans looking to apply for enrollment in the VA health care system. Before beginning, it's helpful to gather the necessary documents and information related to your military service, healthcare coverage, and personal finances.

  1. Section I - General Information: Begin by answering all questions. Fill in your name, preferred name, Social Security number, and various personal details such as birth date and mailing address.
  2. Section II - Military Service Information: Enter your last branch of service, service number, and dates of entry and discharge. Answer any questions regarding military history.
  3. Section III - Insurance Information: Provide details about your health insurance coverage. Include the names and contact information of your insurance companies, policyholder name, policy number, and coverage information.
  4. Section IV - Dependent Information: List your dependents, including your spouse and children. Include details such as names, dates of birth, and Social Security numbers where applicable.
  5. Section V - Employment Information: Indicate your employment status and fill in details about your last job, including company name, address, and phone number.
  6. Section VI - Previous Calendar Year Gross Annual Income: Report your income from all sources, including employment and any other forms of income. Be mindful of what should not be included.
  7. Section VII - Previous Calendar Year Deductible Expenses: Declare any non-reimbursed medical expenses you or your spouse paid throughout the previous year.
  8. Section VIII - Consent to Copays and Communications: Agree to the VA’s copayment policies and indicate whether you consent to receive communications from the VA.
  9. Sign and Date the Form: Make sure to sign and date the form in ink. If necessary, ensure that two witnesses sign if you are signing with an "X".
  10. Attach Supporting Documents: Include any required documents, such as discharge papers or financial records, alongside your application.
  11. Submit Your Application: Mail the completed form and supporting materials to the Health Eligibility Center at the provided address.

Completing the VA Form 10-10EZ accurately is vital to help facilitate the review process and secure the health benefits you need. Make sure to keep copies of everything you submit for your records.

What You Should Know About This Form

What is VA Form 10-10EZ used for?

VA Form 10-10EZ is utilized by veterans to apply for enrollment in the VA health care system. The information provided helps the VA assess eligibility for medical benefits. Typically, it takes about 30 minutes to complete this form, including time to read instructions and gather necessary information.

Where can I get help filling out the form if I have questions?

If assistance is needed while filling out the form, veterans can seek help through various avenues. They can call VA at 1-877-222-VETS (8387) for direct support. Additionally, the VA's website, www.va.gov/health-care, offers valuable information about health benefits. Veterans may also contact the Enrollment Coordinator at their local VA health care facility or reach out to national or state veterans service organizations for further assistance.

What kind of information should I include in Section I?

Section I, titled "General Information," requires veterans to provide personal details. This includes the veteran’s full name, date of birth, social security number, and contact information, among other necessary data. It's essential to answer all questions accurately to facilitate the enrollment process.

Do I need to provide financial information to complete VA Form 10-10EZ?

Financial information is only required for NSC (non-service-connected) and 0% noncompensable SC veterans in Section VI to determine eligibility for enrollment. However, veterans who fall into other categories, such as former Prisoners of War or those receiving VA disability compensation, are exempt from this requirement. If financial disclosure is not provided, it may impact eligibility for certain benefits like cost-free medication or travel assistance.

What do I need to include in Section IV about dependents?

In Section IV, veterans should report details about their dependents. This includes providing information about a spouse, biological children, adopted children, and stepchildren under specific age criteria. Necessary details include names, dates of birth, and whether dependent children were supported financially during the previous calendar year.

How should I handle my health insurance information in Section III?

Section III focuses on health insurance details. Veterans must provide the name, address, and contact number of all health insurance companies covering them, including family coverage. This section is vital for the VA to understand the veteran's existing insurance and how it may interact with VA health care services.

What happens if I do not sign and date the form appropriately?

All applicants are required to sign and date the VA Form 10-10EZ. If the form lacks a signature or the date is missing, the VA will return it for completion. It is crucial to ensure that all required signatures are present to avoid delays in processing the application.

Where should I send my completed form?

Once the form is completed and signed, veterans should mail the original application and any supporting documents to the Health Eligibility Center at 2957 Clairmont Road, Suite 200, Atlanta, GA 30329. Ensuring that all paperwork is correctly submitted is essential for timely processing.

Can I receive care under the VA without filling out this form?

Generally, veterans must complete the VA Form 10-10EZ to enroll in the VA health care system. However, some veterans may qualify for care under specific situations where enrollment is not required. Each scenario varies, so it's important to consult with a VA representative to determine eligibility.

Common mistakes

Filling out the VA Form 10-10EZ is a crucial step for veterans seeking healthcare benefits. Unfortunately, many people make mistakes that can delay or complicate their application process. A common mistake occurs in Section I, where veterans often overlook the importance of accurately providing their name and other personal details. Failing to check for simple errors or missing information, such as the spelling of names or the complete social security number, can lead to significant processing delays.

Another frequent error is in Section II, which pertains to Military Service Information. Many veterans forget to include their discharge type or last discharge date. This information is essential because it helps the VA determine eligibility based on military service. Some also neglect to provide their military history, especially if they served in special circumstances, like as a Purple Heart recipient or former prisoner of war. Omitting this information can result in missed benefits.

In Sections IV and VI, financial disclosure is required only for certain veterans. A common mistake is for individuals to misinterpret these requirements. Some NSC and 0% non-compensable SC veterans skip this section entirely, believing it does not apply to them. Others mistakenly fill it out when it’s not required. Understanding who needs to provide financial information can save time and prevent unnecessary complications.

Finally, many individuals fail to sign and date the form appropriately. It is crucial to remember that missing signatures result in the application being returned for completion. Additionally, anyone signing the application with an "X" needs witnesses to confirm their identity. Ensuring that all areas are correctly filled out and the form is signed can expedite the approval process, allowing veterans to access the healthcare benefits they deserve without delay.

Documents used along the form

The VA Form 10-10EZ is an essential document that Veterans use to apply for enrollment in the VA health care system. Along with this form, several other documents are often required or recommended to streamline the enrollment process. Below is a list of additional documents that may be needed depending on individual circumstances.

  • DD Form 214: This is the Certificate of Release or Discharge from Active Duty. It provides proof of military service and is crucial for determining eligibility for VA benefits.
  • VA Form 10-10SH: If a Veteran is seeking to enroll in the VA Homeless Patient Care program, this form is required to determine eligibility based on housing status.
  • VA Form 21-526EZ: This form is used for applying for VA disability compensation. It may be needed if the application for health benefits is connected to a service-related disability.
  • VA Form 21-534EZ: This form is used by survivors of Veterans to apply for Dependency and Indemnity Compensation (DIC) or survivor benefits. It can be important for those applying based on their dependency status.
  • VA Form 10-10D: This is the application for VA Dental Care. Providing this form can help ensure eligible Veterans receive necessary dental benefits.
  • Medicare or Medicaid Enrollment Cards: If a Veteran is enrolled in these programs, presenting these cards can simplify the verification process of insurance coverage.
  • Financial Documents: Recent tax returns, pay stubs, or bank statements may be required to outline income and assist in determining eligibility for certain benefits.
  • Power of Attorney (POA): If someone is completing the application on behalf of the Veteran, a notarized POA document is necessary to show legal authority.

It’s advisable for Veterans to gather these documents before submitting the VA Form 10-10EZ to enhance the efficiency of the review process. Ensuring that all relevant documentation is in order can help prevent delays in receiving healthcare benefits.

Similar forms

The VA Form 10-10EZ is an essential document for veterans seeking to enroll in the VA health care system. This form shares similarities with several other important documents related to health benefits and eligibility. Here’s a closer look at four documents that bear a resemblance to the VA Form 10-10EZ:

  • VA Form 10-10EZR: This is the Application for Health Benefits and serves as a subsequent annual review for veterans who are already enrolled. It asks about any changes in income or dependent information, similar to how the 10-10EZ collects information to determine eligibility.
  • Medicare Enrollment Application: Like the 10-10EZ, this form is used by individuals to enroll in a health insurance program. Both documents require personal and insurance information to determine eligibility for medical benefits.
  • VA Form 21-526EZ: This is a claim for disability compensation benefits. Both documents require veterans to provide information about their military service and health status, helping to establish eligibility for services and benefits.
  • Health Insurance Marketplace Application: This form is utilized by individuals seeking health coverage through the Affordable Care Act. Much like the VA Form 10-10EZ, it collects personal information, income details, and dependent status to evaluate eligibility for health benefits.

Dos and Don'ts

When filling out the VA Form 10-10EZ, there are important guidelines to follow for a smooth application process. Here are seven things you should and shouldn't do:

  • Do read the instructions carefully before starting to fill out the form.
  • Don't leave any sections blank if they apply to you. This can delay your application.
  • Do attach any necessary documents, like your discharge papers if you're not currently receiving VA benefits.
  • Don't provide false information or omit crucial details, as this can lead to penalties.
  • Do list all sources of income, even if you think they might not be relevant.
  • Don't forget to sign and date the form. An unsigned form will be returned.
  • Do contact the VA for help if you have any questions while completing the form.

Misconceptions

1. The VA Form 10-10EZ is only for veterans with service-connected disabilities. Many veterans believe this form is exclusive to those with service-connected disabilities. In reality, it is used by all veterans seeking enrollment in the VA health care system, regardless of whether they have service-connected conditions.

2. Completion of the form takes a long time. Some think this form requires a significant time investment. However, on average, it typically takes about 30 minutes to complete, including reading instructions and compiling necessary information.

3. Veterans can submit the form without any supporting documentation. It’s a common misconception that supporting documents are unnecessary. Veterans should attach relevant materials, such as discharge papers, to expedite processing, especially if they are new applicants.

4. Only current VA beneficiaries can use the 10-10EZ form. This is not true. Even veterans who are not presently receiving VA benefits can fill out and submit the 10-10EZ to apply for health care enrollment.

5. Financial disclosure is mandatory for all applicants. Many veterans mistakenly believe everyone must provide financial information. Financial disclosure is only required for non-service-connected and 0% noncompensable disability veterans. Certain veterans, like former POWs or those receiving a Purple Heart, do not need to disclose finances.

6. It doesn’t matter how the form is submitted. Some individuals may think submission method is inconsequential. However, it's crucial to mail the original form and any supporting documents to the specific address provided to ensure they are processed correctly.

Key takeaways

The VA Form 10-10EZ is essential for Veterans seeking health care benefits. Understanding how to fill it out correctly can significantly impact your eligibility. Here are six key takeaways:

  • Eligibility Determination: This form is primarily used to determine a Veteran's eligibility for enrollment in the VA health care system.
  • Sections I-III are Mandatory: All Veterans must complete these sections, providing general information, military service details, and health insurance information.
  • Financial Disclosure for Some: Only non-service-connected Veterans and those with a 0% compensation rating need to provide financial information. Failing to do so means you may miss out on certain benefits.
  • Supporting Documents: Attach necessary documents, such as discharge papers, insurance cards, and prior tax returns, as applicable. This can expedite your application process.
  • Signature Requirement: Make sure to sign and date the form. If you cannot sign, have two witnesses present while you do so with an "X". Otherwise, the VA will return it for completion.
  • Submit to the Right Address: Send your completed application and any additional documents to the Health Eligibility Center in Atlanta, GA.

By following these guidelines, you can ensure that your application is processed smoothly and that you receive the benefits you deserve.

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