VA Form 10-10EZ Application for Health Benefits

VA Form 10-10EZ Application for Health Benefits

What Is VA Form 10-10EZ?

VA Form 10-10EZ, Application for Health Benefits , is a legal document the veterans complete to enroll in the U.S. Department of Veterans Affairs (VA) healthcare system. This id the document for all individuals who wish to obtain the VA coverage. The VA uses the information entered on this form to determine the veteran's eligibility for medical benefits.

The latest version of the form was issued on April 1, 2023 , with all previous editions obsolete. You can download a fillable Form 10-10EZ through the link below.

What Is the Deadline for Turning in the 10-10EZ Form for the VA?

Whether you need it right now or not, you are able to take advantage of an entire network of comprehensive VA healthcare and medical benefits, including prescriptions, preventive and primary care, medical equipment, mental healthcare, and dental care. If you have served in the active military, air, or naval service, Reserves, or National Guard and are separated from duty, you may qualify for the VA health benefits. You are free to fill out a 10-10EZ online application at any time convenient for you.

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VA Form 10-10EZ Instructions

  1. Provide your general information - full name, preferred name, mother's maiden name, birth sex, self-identified gender. State your race and add whether you are Spanish, Hispanic, or Latino. Write down your social security number and VA claim number. Indicate your date and place of birth, religious preference, and contact details. State which benefits you are applying for and check the appropriate box if you need minimum essential coverage under the Affordable Care Act. Record the name, address, and contact information of your closest relative and indicate the preference for a VA medical center or outpatient clinic.
  2. Enter your military service information - last branch of service, entry date and discharge dates, the type of discharge, and the military service number. Answer yes or no to questions that cover your military history.
  3. Record your insurance details - name and contact information of the insurance company, name of the policyholder, the number of the policy. State if you are eligible for Medicaid and if you are enrolled in Medicare Part A.
  4. Provide information about your dependents - spouse and children. Write down their names, social security numbers, dates of birth, genders. Specify if the child has a disability and whether your dependents live with you.
  5. Describe your employment - you may work full time, part-time, be unemployed, or retired. Add the date of retirement in the last case. The name, address, and phone number of your current or former employer are required.
  6. Enter your, your spouse's and dependent children's gross annual income - from employment, farm, ranch, property, or business, and list other income amounts.
  7. Indicate the amounts you have paid for funeral and burial expenses, college and educational expenses, and non-reimbursed medical expenses.
  8. Demonstrate your agreement to pay the VA copayments for the care or services.
  9. Sign and date the form.

You may consult the official instructions for the 10-10EZ Form if you have further questions - these can be found on the first two pages of the form. Prepare additional documentation - for instance, health insurance information, financial information, and proof of discharge papers (such as DD Form 214, Certificate of Release or Discharge from Active Duty).

Where to Send VA Form 10-10EZ?

Once you complete Form 10-10EZ, attach necessary continuation sheets, supporting documentation, and a certified copy of the power of attorney if needed and mail the papers to the Health Eligibility Center, 2957 Clairmont Road, Suite 200, Atlanta, GA 30329.


Related VA 10-10 Forms:

Other Revisions

Download VA Form 10-10EZ Application for Health Benefits

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