What is the Va Form 10 10Ezr? The Va Form 10 10Ezr is an application for veterans seeking disability compensation. This form can be used to apply for benefits for service-connected disabilities or to appeal a decision made by the Department of Veterans Affairs (VA). The VA Form 10 10Ezr is also used to request reimbursement for medical expenses related to a service-connected disability. If you are a veteran with a service-connected disability, make sure you are familiar with this form and how to complete it. By understanding the process and what information is required, you can submit your application quickly and easily. Let's take a closer look at the Va Form 10 10Ezr and what it entails.
We've collected some technical details about the va form 10 10ezr. There, you will find the details about the form you intend to fill in, like the estimated time to fill it out as well as other details.
Question | Answer |
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Form Name | Va Form 10 10Ezr |
Form Length | 4 pages |
Fillable? | No |
Fillable fields | 0 |
Avg. time to fill out | 1 min |
Other names | va form 1010ezr, va 10 10ezr, va means test, va form 10 10ezr |
INSTRUCTIONS FOR COMPLETING
HEALTH BENEFITS UPDATE FORM
Please Read Before You Start . . . What is VA Form
VA Form
Where can I get help filling out the form and if I have questions? This update form is available for completion online at
You may use ANY of the following to request assistance:
•Ask VA to help you fill out the form by calling us at
•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
SPOUSE: If you are certifying that a person is your spouse for the purpose of VA benefits, your marriage must be recognized by the place where you and/or your spouse resided at the time of marriage, or where you and/or your spouse reside when you file your claim (or at a later date when you become eligible for benefits) (38 U.S.C. 103(c)). Additional guidance on when VA recognizes marriages is available at http://www.va.gov/opa/marriage/.
ALL VETERANS MUST COMPLETE SECTIONS I, II, VI, and VII
Directions for Sections I - II:
Section I - General Information: Answer all questions.
Section II - Insurance Information: Include information for all health insurance companies that cover you, this includes coverage provided through a spouse or significant other. If you have more than one health insurer, provide this information on a separate sheet of paper and attach to the application. If you have access to a copier, attach a copy of your insurance cards, Medicare card and/or Medicaid card (Medicaid is a federal/state health insurance program for certain
COMPLETE SECTION III only if you complete Sections IV:
Section III - Dependent Information: Your spouse and dependent social security numbers(s) are required so we can verify their financial information through a
Directions for Sections IV - V:
Veterans may provide a financial assessment to update their eligibility for
Veterans rated
Complete only the sections that apply to you; sign and date the form.
VA FORM |
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JUL 2021 |
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Section IV - 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 Compensation 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 V - Previous Calendar Year Deductible Expenses.
Report
Section VI - 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.
Section VII - Submitting Your Update.
1.Read Paperwork Reduction and Privacy Act Information, Section VI Consent to Copays and Assignment of Benefits.
2.Sign and Date the form. 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.
3.Attach any continuation sheets, a copy of supporting materials or your Power of Attorney documents to your application.
Where do I mail my update?
Mail the completed VA Form
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 15 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 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 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 |
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OMB Approved No.
HEALTH BENEFITS UPDATE FORM
SECTION I - GENERAL INFORMATION
Federal law provides criminal penalties, including a fine and/or imprisonment, for any materially false, fictitious, or fraudulent statement or representation. (See 18 U.S.C. 287 and 1001).
VA DATE STAMP
(For VHA Use Only)
1A. VETERAN'S NAME (Last, First, Middle Name) |
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2. SOCIAL SECURITY NUMBER |
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1B. VETERAN'S PREFERRED NAME (Last, First, Middle Name) |
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3A. BIRTH SEX |
3B. |
4. DATE OF BIRTH |
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5. HOME TELEPHONE NUMBER (optional) |
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MALE |
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MALE |
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FEMALE |
(mm/dd/yyyy) |
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(Include area code) |
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FEMALE |
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6. MOBILE TELEPHONE NUMBER (optional) |
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CHOOSE NOT TO ANSWER |
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(Include area code) |
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7A. MAILING ADDRESS (Street) |
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7B. CITY |
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7C. STATE |
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7D. ZIP CODE |
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7E. COUNTY |
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8A. HOME ADDRESS (Street) |
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8B. CITY |
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8C. STATE |
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8D. ZIP CODE |
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8E. COUNTY |
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9. |
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10. CURRENT MARITAL STATUS |
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MARRIED |
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NEVER MARRIED |
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SEPARATED |
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WIDOWED |
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DIVORCED |
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SECTION II - 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? (Federal Health Insurance for low income adults)
YES NO
6. ARE YOU ENROLLED IN MEDICARE HOSPITAL INSURANCE PART A?
YES
NO
7. EFFECTIVE DATE (mm/dd/yyyy)
SECTION III - DEPENDENT INFORMATION (Use a separate sheet for additional dependents)
1. SPOUSE'S NAME (Last, First, Middle Name) |
7. CHILD'S NAME (Last, First, Middle Name) |
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2. SPOUSE'S SOCIAL SECURITY NUMBER |
8. CHILD'S DATE OF BIRTH (mm/dd/yyyy) |
9. CHILD'S SOCIAL SECURITY NUMBER |
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3. SPOUSE'S DATE OF BIRTH (mm/dd/yyyy) |
10. DATE CHILD BECAME YOUR DEPENDENT (mm/dd/yyyy) |
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4. SPOUSE'S |
11. CHILD'S RELATIONSHIP TO YOU (Check one) |
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MALE |
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FEMALE |
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SON |
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DAUGHTER |
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STEPSON |
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STEPDAUGHTER |
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12. WAS CHILD PERMANENTLY AND TOTALLY DISABLED BEFORE THE AGE OF 18? |
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CHOOSE NOT TO ANSWER |
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YES |
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NO |
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5. DATE OF MARRIAGE (mm/dd/yyyy) |
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13. IF CHILD IS BETWEEN 18 AND 23 YEARS OF AGE, DID CHILD ATTEND |
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SCHOOL LAST CALENDAR YEAR? |
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6. SPOUSE'S ADDRESS AND TELEPHONE NUMBER |
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(Street, City, State, ZIP - if different from Veteran's) |
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14. EXPENSES PAID BY YOU FOR YOUR DEPENDENT CHILD FOR COLLEGE, |
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VOCATIONAL REHABILITATION OR TRAINING (e.g., tuition, books, materials) |
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15. IF YOUR SPOUSE OR DEPENDENT CHILD DID NOT LIVE WITH YOU LAST YEAR, DID YOU PROVIDE SUPPORT?
YES
NO
REMEMBER TO SIGN AND DATE THE FORM ON THE REVERSE PAGE
PREVIOUS EDITIONS OF THIS FORM ARE NOT TO BE USED
VA FORM |
HEC PAGE 3 OF 4 |
HEALTH BENEFITS UPDATE FORM
VETERAN'S NAME (Last, First, Middle)
SOCIAL SECURITY NUMBER
SECTION IV - PREVIOUS CALENDAR YEAR GROSS ANNUAL INCOME OF VETERAN, SPOUSE AND DEPENDENT CHILDREN
(Use a separate sheet for additional dependents)
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VETERAN |
SPOUSE |
CHILD 1 |
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1. GROSS ANNUAL INCOME FROM EMPLOYMENT (wages, bonuses, tips, |
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etc.) EXCLUDING INCOME FROM YOUR FARM, RANCH, PROPERTY OR |
$ |
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BUSINESS |
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2. NET INCOME FROM YOUR FARM, RANCH, PROPERTY OR BUSINESS |
$ |
$ |
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3.LIST OTHER INCOME AMOUNTS (e.g., Social Security, compensation,
pension, interest, dividends) EXCLUDING WELFARE. |
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SECTION V - PREVIOUS CALENDAR YEAR DEDUCTIBLE EXPENSES |
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1. TOTAL |
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Medicare, health insurance, hospital and nursing home) VA will calculate a deductible and the net medical expenses you may claim. |
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2. AMOUNT YOU PAID LAST CALENDAR YEAR FOR FUNERAL AND BURIAL EXPENSES (INCLUDING PREPAID BURIAL EXPENSES) |
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FOR YOUR DECEASED SPOUSE OR DEPENDENT CHILD (Also enter spouse or child's information in Section III.) |
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3. AMOUNT YOU PAID LAST CALENDAR YEAR FOR YOUR COLLEGE OR VOCATIONAL EDUCATIONAL EXPENSES (e.g., tuition, books, |
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fees, materials) DO NOT LIST YOUR DEPENDENTS' EDUCATIONAL EXPENSES. |
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SECTION VI - 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
SECTION VII - SUBMITTING YOUR UPDATE
ALL APPLICANTS MUST SIGN AND DATE THIS FORM. REFER TO INSTRUCTIONS WHICH DEFINE WHO CAN SIGN ON BEHALF OF THE VETERAN.
Federal law provides criminal penalties, including a fine and/or imprisonment, for any materially false, fictitious, or fraudulent statement or representation. (See 18 U.S.C. 287 and 1001).
I declare under penalty of perjury that the foregoing is true and accurate to the best of my knowledge. I understand that any materially false, fictitious, or fraudulent statement or representation, made knowingly, is punishable by a fine and/or imprisonment pursuant to title 18, United States Code, Sections 287 and 1001.
SIGNATURE OF APPLICANT: |
DATE (mm/dd/yyyy): |
(Sign in ink) |
VA FORM |
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