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Va Form 10 10ez

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The VA Healthcare Application, officially known as a VA Form 10-10EZ is an application that veterans use to apply for health benefits. Used by the United States Department of Veterans Affairs, this form is used by all individuals who wish to be covered by the VA’s healthcare system. VA Form 10-10EZ collects particular information from a veteran in order to determine eligibility. Typically two pages in length, this document takes an average of 30 minutes to complete and collects information such as a veteran’s full name, address, social security number, military service information, and current insurance information.

Va Form 10 10ez

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What is a VA Form 10 10EZ?

A VA Form 10-10EZ is known as an easier version of the Enrollment Application for Health Benefits. This form is used by the United States Department of Veterans Affairs. This form will be completed by veterans who wish to become covered under the VA health care system. This particular form is used to determine the party’s eligibility for medical benefits and is two pages long.
This form requires personal information about the veteran, including full name, address, social security number, and marital status. The veteran will then have the option to list what VA medical center or clinic they prefer. The next section will detail the veteran’s military history. This is used to verify that the filer meets the qualifications for veteran’s medical services.
 

Most Common Uses

The VA Form 10-10EZ is commonly used by veterans to apply for medical care through the VA.  If you serviced in active duty in the military, Reserves, or National Guard, you may be eligible for benefits.

Components of a VA Form 10 10EZ

A VA Form 10-10EZ contains the following sections:

  • General information
  • Military Service Information
  • Insurance Information
  • Dependent Information
  • Employment Information
  • Previous Calendar Year Financial Information
  • Consent to Copays and to Receive Communications
  • Signature

How to Apply for Healthcare Benefits

To apply for healthcare benefits, you need to fill out a VA Form 10-10EZ.  After submitting the form, you will get a confirmation message.  The VA processes health care claims within a week.  If you have submitted an application more than one week ago and haven’t heard back, you should call 1-877-222-8387. 

How to complete a VA form 10 10EZ (Step by Step)

To complete a VA Form 10-10EZ, you will need to provide the following information:

  • General information
    • Veteran’s name
    • Preferred name
    • Mother’s maiden name
    • Birth sex
    • Self-identified gender identity
    • Whether you are Spanish, Hispanic, or Latino
    • Race: Asian, American Indian or Alaska native, Black or African American, White, Native Hawaiian or other Pacific Islander
    • Social Security number
    • VA claim number
    • Date of birth
    • Place of birth
    • Religion
    • Permanent Address - street, city, state, zip code, county
    • Telephone number
    • Email address
    • Residential address
    • Type of benefits applying for
    • Current marital status
    • Next of kin name, address, relationship, phone number
    • Designee to receive possession of personal property left on premises under VA control after departure or time of death
    • Whether you are enrolling to obtain minimum essential coverage under the Affordable Care Act
    • Preferred VA Medical Center or Outpatient Clinic
    • Whether you would like for VA to contact you to schedule your first appointment 
  • Military Service Information
    • Last branch of service 
    • Last entry date
    • Future discharge date
    • Last discharge date
    • Discharge type
    • Military service number
    • Military history
  • Insurance Information
    • Health insurance company name, address, telephone number
    • Name of policy holder
    • Policy number
    • Group code
    • Whether you are eligible for Medicaid
    • Whether you are enrolled in Medicare hospital insurance Part A
  • Dependent Information
    • Spouse’s name
    • Spouses’ social security number
    • Spouse’s date of birth
    • Spouse self-identified gender identity
    • Date of marriage
    • Spouse’s address and phone number
    • Child’s name
    • Child’s date of birth
    • Child’s social security number
    • Date child became your dependant 
    • Child’s relationship to you
    • Whether child was permanently and totally disabled before the age of 18
    • Whether child is between 18 and 23 years of age and attended school last calendar year
    • Expenses paid by your dependent child for college, vocational rehabilitation, or training 
  • Employment Information
    • Veteran’s Employment status
    • Date of retirement
    • Company name
    • Company address
    • Company phone number
  • Previous Calendar Year Annual Income of Veteran, Spouse, and Dependent Children
    • Gross annual income from employment excluding income from farm, ranch, property or business
    • Net income from farm, ranch, property, or business
    • Other income amounts
  • Previous Calendar Year Deductible Expenses
    • Total medical expenses paid by you or your spouse for which you did not receive monetary compensation
    • Amount you paid last calendar year for funeral and burial expenses for your deceased spouse or dependent child
    • Amount you paid last year for your college or vocational educational expenses
  • Consent to Copays and to Receive Communications
  • Signature

Legal Considerations

What should I do before I apply?

Before you apply for health benefits, you should ensure that you are eligible to receive them.  You may be eligible for VA benefits if you served in the active military, naval, or air service and didn’t receive a dishonorable discharge.  You should also collect all relevant supporting documents such as your recent tax return, social security numbers for yourself and your dependents, and insurance cards, Medicaid cards, and account numbers for any current health insurance that you have.

How do I apply?

You can apply online (http://www.va.gov/health-care/apply/application/veteran-information/personal-information), by phone at 1-877-222-VETS (1-877-222-8387), by filling out a VA Form 10-10EZ and mailing it to: Health Eligibility Center, 2957 Clairmont Road, Suite 200, Atlanta, GA 30329, or going to your local VA medical center or clinic and filling out VA Form 10-10EZ in person.

Sample Va Form 10 10ez

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Sample Va Form 10 10ez

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