VA Form 10-10ez: Healthcare Application

What is a 10-10EZ? The VA Form 10-10EZ allows veterans to apply for enrollment in the VA health care system. The VA uses the information provided on the form to determine the veteran’s eligibility for medical benefits. Usually, the form only takes about 30 minutes to complete. Veterans who require assistance completing the form may:

• Call the VA at 1-800-698-2411 (1-800-MyVA411)
• Visit the VA’s website
• Contact the Enrollment Coordinator at their local VA health care facility
• Contact a National or State Veterans Service Organization

Definitions of Terms Used on This Form

There are several important terms included on this form. Definitions of these terms are as follows:

• Service-connected (SC): a determination by the VA that an injury or illness was incurred or made worse in the line of duty during active military service
• Compensable: a determination by the VA that a service-connected disability is severe enough to warrant financial compensation to the veteran
• Noncompensable: a determination by the VA that a service-connected disability is not severe enough to warrant financial compensation to the veteran
• Non-service-connected (NSC): veterans who do not have a service-related condition as determined by the VA

Components of a VA Form 10-10EZ

There are eight main sections of the VA Form 10 10EZ. They include general information, information about the veteran’s military service, insurance, financial, dependent, and income information.

General information

The general information section includes the following fields:

• Veteran’s first, middle, and last name, as well as their preferred name
• Mother’s maiden name
• Birth sex and self-identified gender identity
• Race
• Social security number
• VA claim number
• Date and place of birth
• Religion
• Permanent address, including city, state, county, and zip code, as well as residential address
• Optional information: home phone, mobile phone, and email
• The type of benefits being applied for
• Current marital status
• Next of kin information: name, address, relationship, telephone
• Designee name: the individual who will receive any of the veteran’s personal property left on VA premises
• Whether or not the veteran is enrolling in coverage to obtain minimum essential coverage under the Affordable Care Act
• The veteran’s preferred VA medical center or outpatient clinic
• Whether or not the veteran wants to be contacted by the VA to schedule their first appointment

Military Service Information

Veterans currently not receiving VA benefits may attach a copy of their military discharge or separation papers, such as a DD-214, with their signed application to expedite the processing of their application. For veterans already receiving benefits, the VA will cross-reference the information on the form with VA data. Military service information includes the following:

• Last branch of service and last entry date
• Future discharge date or last discharge date, and discharge type
• Military service number
• Yes or no military history questions, including:
  • Purple Heart award recipient?
  • Former prisoner of war?
  • Served in combat after 11/11/1998?
  • Discharged or retired for a disability incurred in the line of duty?
  • Receiving disability retirement pay instead of compensation from the VA?
  • Served in Southwest Asia between 8/2/1990 and 11/11/1998?
  • Service-connected rating? If yes, what percentage?
  • Served in Vietnam between 1/9/1962 and 5/7/1975?
  • Exposed to radiation while in the military?
  • Received nose and throat radium treatments while in the military?
  • Served on active duty for at least 30 days at Camp Lejeune from 8/1/1953 through 12/31/1987?

Insurance Information

Veterans should include information for all health insurance sources, including insurance through a spouse. Insurance information includes:

• Health insurance company name, address, and phone number. If the veteran is covered by insurance through their spouse or someone else, they should include that as well
• Policyholder name, policy number, and group code
• Whether or not the veteran is eligible for Medicaid, or if they are enrolled in Medicare Hospital Insurance Part A, and the effective date

Dependent Information

Dependent information should include the veteran’s spouse (even if they did not live together, as long as the veteran contributed support in the last calendar year); biological, adopted, and stepchildren who are unmarried and younger than 18 years old, or are 18-23 and attending high school, college or vocational school, or are permanently unable to support themselves before age 18. A separate sheet must be used for additional dependents.

For spouses:

• First, middle and last name of spouse;
• Spouse’s Social Security number, date of birth, and self-identified gender identity;
• Date of marriage; and
• Spouse’s address and phone number.
  

  For children:

  • First, middle and last name of child;
  • Child’s Social Security Number, date of birth, the date the child became the veteran’s dependent, and the child’s relationship to the veteran;
  • Whether or not the child was disabled before the age of 18;
  • Whether or not the child attended school in the last calendar year if they are between 18- 23 years old;
  • Any expenses paid by the dependent child for college or other training;
  • Whether or not the veteran provided support for spouses or dependent children not living with them in the last calendar year.

Employment Information

• The veteran’s employment status: full-time, part-time, not employed, or retired
• If retired, the date of retirement
• For employed or retired veterans: company name, address, and phone number

Previous Calendar Year Gross Annual Income of Veteran, Spouse and Dependent Children

In this section, income from the veteran, spouse, and any dependent children for the following:

• Gross-annual income from employment, including wages, tips, severance pay, and accrued benefits. Include income for dependent children if it could have been used to pay household expenses.
• Net income from the veteran’s property, business, farm, or ranch.
• Retirement and pension income, Social Security Retirement and Social Security Disability Income, VA disability benefits, unemployment, interest and dividends, and tax-exempt earnings and distributions from Individual Retirement Accounts.

The following should not be reported in this section:

• Donations from public or private charitable organizations
• Supplemental Security Income and need-based payments from government agencies
• Scholarships and grants for school attendance
• Income tax refunds or reinvested interests on Individual Retirement Accounts
• Loans
• Payments for exposure to radiation or Agent Orange
• Payments to foster parents
• Payments received under the Medicare transitional assistance program

Previous Calendar Year Deductible Expenses

This section should include the following:

• Total unreimbursed medical expenses, paid by the veteran or their spouse, such as payments for health insurance, medical or dental care, medications, and hospital or nursing home stays. The VA will calculate a deductible and the net medical expenses the veteran may claim
• The amount the veteran paid the previous calendar year for burial and funeral expenses for their spouse or dependent child who is deceased
• The amount the veteran paid the previous calendar year for their college or vocational expenses, such as books, fees, tuition, or materials. Dependents’ educational expenses should NOT be included in this section

Consent to Copays and to Receive Communications

This section informs the veteran that by submitting the application, they agree to pay any applicable VA copayments for care or services as required by law (including urgent care). The veteran also agrees to receive communication from the VA to the email, home phone number, or mobile phone number they have provided; however, providing these is not required.

Signature

By signing this form, the veteran acknowledges the following:

• That the VA is authorized to collect reasonable charges for non-service-connected VA services or medical care from the veteran’s health plan or another legally responsible third party
• The veteran authorizes payment to the VA from any health plan they are covered under for any charges for non-service-connected medical care
• That the veteran authorizes the VA to disclose information from their medical records as necessary to verify their claim to a third party (such as an attorney), and any third party to disclose information regarding the veteran’s claim to the VA

Submitting The Application

Once the form has been completed, the veteran or their power of attorney must sign and date it. If the form is signed with an “X,” two people the veteran knows must witness their signature and must sign and print their names on the form. For VA to accept the form, it must be appropriately signed and dated. Otherwise, it will be returned to the veteran for them to complete.

Additionally, any continuation sheets, copies of supporting materials, and Power of Attorney documents should be attached to the application. The completed application (and any supporting materials) can either be submitted in person at the veteran’s local VA clinic or medical center or mailed to Health Eligibility Center, 2957 Clairmont Road, Suite 200, Atlanta, GA 30329.