Fillable Form VA 10-10EZR - Health Benefits Update Form

What is Form VA 10-10EZR?

Form VA 10-10EZR, Health Benefits Update Form, is a legal form issued by the U.S. Department of Veterans Affairs (VA) that is used by veterans to update their personal, insurance, or financial information. Applicants of this form should be enrolled with the VA health care benefits.

How to fill out Form VA 10-10EZR?

Form VA 10-10EZR is a two-page document. Do not leave the required items blank to avoid any problems with your request.

Note: All Veterans must complete Sections I, II, VI, and VII.

Page 1 of 2

SECTION I - GENERAL INFORMATION

Box 1 – Veteran’s Name

Enter your full legal name in the following format: Last Name, First Name, and Middle Name.

Box 2 – Social Security Number

Enter your Social Security Number.

Box 3 – Gender

Mark the appropriate box to determine your gender. You may select:

• Male
• Female

Box 4 – Date of Birth

Enter your birthdate in the following format: Month, Day, and Year.

Box 5 – Home Telephone Number

Enter your active home telephone number including the area code.

Box 6 – Mobile Telephone Number

Enter your active mobile telephone number include the area code.

Box 7 – Permanent Address

Enter your permanent address including the street.

Box 8 – City

Enter your city.

Box 9 – State

Enter your state.

Box 10 – ZIP Code

Enter your ZIP code.

Box 11 – County

Enter your county.

Box 12 – E-mail Address

Enter your complete e-mail address.

Box 13 – Current Marital Status

Mark the appropriate box to determine your current marital status. You may select:

• Married
• Never Married
• Separated
• Widowed
• Divorced

SECTION II - INSURANCE INFORMATION

Use a separate sheet for additional information.

Box 1 – Health Insurance Company Name, Address, and Telephone Number

Enter the full legal name of your health insurance company, address, and telephone number.

Include coverage through a spouse or other people.

Box 2 – Name of Policy Holder

Enter the full legal name of the policy holder.

Box 3 – Policy Number

Enter the policy number.

Box 4 – Group Code

Enter the group code.

Box 5 – Are You Eligible For Medicaid?

Mark the appropriate box to determine if you are eligible for Medicaid. You may select:

• Yes
• No

Box 6 – Are You Enrolled in Medical Hospital Insurance Part A?

Mark the appropriate box to determine if you are enrolled in medical hospital insurance part A. You may select:

• Yes
• No

Box 7 – Effective Date

Enter the effective date in the following format: Month, Day, and Year.

SECTION III - DEPENDENT INFORMATION

Complete Section III only if you completed Section IV.

Use a separate sheet for additional dependents.

Box 1 – Spouse’s Name

Enter the full legal name of your spouse in the following format: Last Name, First Name, and Middle Name.

Box 2 – Spouse’s Social Security Number

Enter the Social Security Number of your spouse.

Box 3 – Spouse’s Date of Birth

Enter the birthdate of your spouse in the following format: Month, Day, and Year.

Box 4 – Date of Marriage

Enter your date of marriage in the following format: Month, Day, and Year.

Box 5 – Spouse’s Address and Telephone Number

Enter your spouse’s complete address and active telephone number.

Box 6 – Child’s Name

Enter your child’s name in the following format: Last Name. First Name, and Middle Name.

Box 7 – Child’s Date of Birth

Enter the birthdate of your child in the following format: Month, Day, and Year.

Box 8 – Child’s Social Security Number

Enter the Social Security Number of your child.

Box 9 – Date Child Become Your Dependent

Enter the date when your child became your dependent in the following format: Month, Day, and Year.

Box 10 – Child’s Relationship To You

Mark the appropriate box to determine your child’s relationship with you. You may select:

• Son
• Daughter
• Stepson
• Stepdaughter

Box 11 – Was Child Permanently and Totally Disabled Before the Age of 18?

Mark the appropriate box to determine if your child was permanently and totally disabled before the age of 18. You may select:

• Yes
• No

Box 12 – If Child is Between 18 and 23 Years of Age, Did Child Attend School Last Calendar Year?

Mark the appropriate box to determine if your child attended school last calendar year. You may select:

• Yes
• No

Box 13 – Expenses Paid by You for Your Dependent Child for College, Vocational Rehabilitation, or Training

Enter the expenses you paid for your child for college, vocational rehabilitation, or training.

Box 14 – If Your Spouse or Dependent Child Did Not Live With You Last Year, Did You Provide Support?

Mark the appropriate box to determine if you provided support to your spouse and child. You may select:

• Yes

• No

Page 2 of 2

Veteran’s Name

Enter your full legal name in the following format: Last Name, First Name, and Middle Name.

Social Security Number

Enter your Social Security Number

SECTION IV - PREVIOUS CALENDAR YEAR GROSS ANNUAL INCOME OF VETERAN, SPOUSE, AND DEPENDENT CHILDREN

Use a separate sheet for additional dependents

For each item, enter the amount in dollars for the Veteran, Spouse, and Child 1.

1. Gross annual income from employment (wages, bounces, tips, etc.) excluding income from your farm, ranch, property, or business.
2. Net income from your farm, ranch, property, or business.
3. List other income accounts excluding welfare.

Examples are Social Security, compensation, pension, interest, and dividends.

SECTION V - PREVIOUS CALENDAR YEAR DEDUCTIBLE EXPENSES

For each item, enter the amount in dollars.

1. Total non-reimbursed medical expenses paid by you or your spouse.

Examples are payments for doctors, dentists, medications, Medicare health insurance, hospital, and nursing home)

The VA will calculate a deductible and the net medical expenses you may claim.

1. Amount you paid last calendar year for funeral and burial expenses for your deceased spouse or dependent child.
2. Amount you paid last calendar year for your college or vocational educational expenses.

Do not list your dependents’ educational expenses.

SECTION VI - CONSENT TO COPAYS AND TO RECEIVE COMMUNICATIONS

This section includes that you agree to pay the applicable VA copays for treatments and services of your NSC conditions and to receive communications from VA.

ASSIGNMENT OF BENEFITS

This section includes an agreement in which the policy's insurance claims rights or benefits are transferred to a third party.

SECTION VII - SUBMITTING YOUR UPDATE

Signature of Applicant

Affix your signature.

Date

Enter the date when you signed this form.

Where to submit Form VA 10-10EZR?

You can submit the completed Form VA 10-10EZR and any supporting materials via mailing it to:

Health Eligibility Center

2957 Clairmont Road, Suite 200

Atlanta, GA 30329