For new and soon-to-be veterans, the process of filing for VA benefits can seem daunting. However, with the help of the VA Form 10 10Ez, the application process is simplified. This easy-to-use form can be completed in a matter of minutes, and ensures that all necessary information is submitted to the VA. In this post, we'll provide an overview of the VA Form 10 10Ez, and walk you through the steps for completing it.
The following are some details about va form 10 10ez. You might like to read it before filling in the form.
Question | Answer |
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Form Name | Va Form 10 10Ez |
Form Length | 5 pages |
Fillable? | No |
Fillable fields | 0 |
Avg. time to fill out | 1 min 15 sec |
Other names |
INSTRUCTIONS FOR COMPLETING ENROLLMENT
APPLICATION FOR HEALTH BENEFITS
Please Read Before You Start . . . What is VA Form
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
•Access VA's website at http://www.va.gov and select "Contact the VA."
•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:
COMPENSABLE: A VA determination that a
NONCOMPENSABLE: A VA determination that a
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
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
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
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
•Child support contributions. Contributions can include tuition or clothing payments or payments of medical bills.
VA FORM |
Complete only the sections that apply to you; sign and date the form. |
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JAN 2020 |
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PAGE 1 OF 5
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Section V - Employment Information: |
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Veterans Employment Status |
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Company Address |
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Date of Retirement |
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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
Section VII - Previous Calendar Year Deductible Expenses
Report
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
VA FORM |
PAGE 2 OF 5 |
OMB Control No.
Estimated Burden Avg. 30 min.
Expiration Date 12/31/2020
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)
1A. VETERAN'S NAME (Last, First, Middle Name)
1B. PREFERRED NAME
2. MOTHER'S MAIDEN NAME
3A. BIRTH SEX
MALE
FEMALE
3B.
MALE
FEMALE
4.ARE YOU SPANISH, HISPANIC,OR LATINO?
YES
NO
5.WHAT IS YOUR RACE? (You may check more than one. Information is required for statistical purposes only.)
ASIAN |
AMERICAN INDIAN OR ALASKA NATIVE |
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BLACK OR AFRICAN AMERICAN |
WHITE |
NATIVE HAWAIIAN OR OTHER PACIFIC ISLANDER
6. SOCIAL SECURITY NO.
7. VA CLAIM NUMBER
8A. DATE OF BIRTH (mm/dd/yyyy)
8B. PLACE OF BIRTH (City and State)
9. RELIGION
10A. PERMANENT ADDRESS (Street)
10B. CITY
10C. STATE
10D. ZIP CODE
10E.COUNTY
10F. HOME TELEPHONE NO. (optional) |
10G. MOBILE TELEPHONE NO. (optional) |
10H. |
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(Include Area Code) |
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(Include Area Code) |
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11A. RESIDENTIAL ADDRESS (Street) |
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11B. CITY |
11C. STATE |
11D. ZIP CODE |
11E.COUNTY |
12. TYPE OF BENEFIT(S) APPLYING FOR |
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13. CURRENT MARTIAL STATUS |
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(You may check more than one) |
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ENROLLMENT/HEALTH SERVICES
DENTAL
MARRIED
NEVER MARRIED
SEPARATED
WIDOWED
DIVORCED
14A. NEXT OF KIN NAME
14B. NEXT OF KIN ADDRESS |
14C. NEXT OF KIN RELATIONSHIP |
14D. NEXT OF KIN TELEPHONE NO. |
14E. NEXT OF KIN WORK TELEPHONE NO. |
(Include Area Code) |
(Include Area Code) |
15.DESIGNEE - INDIVIDUAL TO RECEIVE POSSESSION OF YOUR PERSONAL 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)
16.I AM ENROLLING TO OBTAIN MINIMUM ESSENTIAL COVERAGE UNDER THE AFFORDABLE CARE ACT
YES |
NO |
17.WHICH VA MEDICAL CENTER OR OUTPATIENT CLINIC DO YOU PREFER?
(for listing of facilities visit www.va.gov/directory)
18.WOULD YOU LIKE FOR VA TO CONTACT YOU TO SCHEDULE YOUR FIRST APPOINTMENT?
YES |
NO |
SECTION II - MILITARY SERVICE INFORMATION
1A. LAST BRANCH OF SERVICE
1B. LAST ENTRY DATE
1C. FUTURE DISCHARGE DATE
1D. LAST DISCHARGE DATE
1E. DISCHARGE TYPE |
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1F. MILITARY SERVICE NUMBER |
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2. MILITARY HISTORY (Check yes or no) |
YES NO |
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YES |
NO |
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A. ARE YOU A PURPLE HEART AWARD RECIPIENT? |
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G. DO YOU HAVE A VA |
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B. ARE YOU A FORMER PRISONER OF WAR? |
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IF "YES", WHAT IS YOUR RATED PERCENTAGE |
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% |
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C. DID YOU SERVE IN A COMBAT THEATER OF OPERATIONS AFTER |
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H. DID YOU SERVE IN VIETNAM BETWEEN JANUARY 9, 1962 |
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11/11/1998? |
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AND MAY 7, 1975? |
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D. WERE YOU DISCHARGED OR RETIRED FROM MILITARY FOR A |
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I. WERE YOU EXPOSED TO RADIATION WHILE IN THE |
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DISABILITY INCURRED IN THE LINE OF DUTY? |
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MILITARY? |
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E. ARE YOU RECEIVING DISABILITY RETIREMENT PAY INSTEAD OF |
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J. DID YOU RECEIVE NOSE AND THROAT RADIUM |
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VA COMPENSATION? |
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TREATMENTS WHILE IN THE MILITARY? |
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F. DID YOU SERVE IN SW ASIA DURING THE GULF WAR BETWEEN |
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K. DID YOU SERVE ON ACTIVE DUTY AT LEAST 30 DAYS AT |
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CAMP LEJEUNE FROM AUGUST 1, 1953 THROUGH |
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AUGUST 2, 1990 AND NOVEMBER 11, 1998? |
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DECEMBER 31, 1987? |
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VA FORM |
PREVIOUS EDITIONS OF THIS FORM ARE NOT TO BE USED |
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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?
YES NO
6A. ARE YOU ENROLLED IN MEDICARE HOSPITAL INSURANCE PART A?
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 BIRTH
(mm/dd/yyyy)
1C. SPOUSE |
2C. DATE CHILD BECAME YOUR DEPENDENT (mm/dd/yyyy) |
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GENDER IDENTITY |
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MALE |
FEMALE |
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1D. DATE OF MARRIAGE (mm/dd/yyyy) |
2D. CHILD'S RELATIONSHIP TO YOU (Check one) |
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SON |
DAUGHTER |
STEPSON |
STEPDAUGHTER
1E. SPOUSE'S ADDRESS AND TELEPHONE NUMBER (Street, City, State, ZIP if different from Veteran's)
2E. WAS CHILD PERMANENTLY AND TOTALLY DISABLED BEFORE THE AGE OF 18?
YES |
NO |
2F. IF CHILD IS BETWEEN 18 AND 23 YEARS OF AGE, DID CHILD ATTEND SCHOOL LAST CALENDAR YEAR?
YES
NO
3.IF YOUR SPOUSE OR DEPENDENT CHILD DID NOT LIVE WITH YOU LAST YEAR, DID YOU PROVIDE SUPPORT?
YES |
NO |
2G. EXPENSES PAID BY YOUR DEPENDENT CHILD FOR COLLEGE, VOCATIONAL REHABILITATION OR TRAINING (e.g., tuition, books, materials)
SECTION V - EMPLOYMENT INFORMATION
1A. VETERAN'S EMPLOYMENT STATUS (Check one).
FULL TIME |
PART TIME |
NOT EMPLOYED
RETIRED
1B. DATE OF RETIREMENT
1C. COMPANY NAME.
(Complete if employed or retired)
1D. COMPANY ADDRESS
(Complete if employed or retired - Street, City, State, ZIP )
1E. COMPANY PHONE NUMBER
(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
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 |
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
ALL APPLICANTS MUST SIGN AND DATE THIS FORM. REFER TO INSTRUCTIONS WHICH DEFINE WHO CAN SIGN ON BEHALF OF THE VETERAN.
SIGNATURE OF APPLICANT
(Sign in ink)
DATE
VA FORM |
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