VA Form 10-10EZ Application for Health Benefits

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:

• VA Form 10-10D (used to apply for the health benefits program);
• VA Form 10-10CG (used for applying to join the Comprehensive Assistance for Family Caregivers Program);
• VA Form 10-10M (attests the results of a veteran's medical examination);
• VA Form 10-10EZR (used for updating the applicant's personal, insurance, or financial information);
• VA Form 10-10SH (necessary to apply for quality care for the veterans in a nursing home, domiciliary, and adult day health care);
• VA Form 10-10EC (used to apply for assisted living, residential (live-in) or home health care through VA);
• VA Form 10-10HS (used by the veterans whose gross household income has decreased).