Fillable Form VA 10-10EZ (2020)

What is VA Form 10-10EZ?

VA Form 10-10EZ, Application for Health Benefits, permits veterans to apply for VA health care. A veteran’s eligibility for medical benefits is determined through the information provided in the form. In general, his or her eligibility will be determined if an illness or injury was incurred or aggravated while serving in the active military, naval, or air service. All veterans must fill out factual information during their time of service.

How to fill out VA Form 10-10EZ?

Filling out VA Form 10-10EZ usually takes 30 minutes to complete. Falsifying information is liable for criminal penalties, such as fine or imprisonment for up to 5 years, under federal law.

SECTION 1 – GENERAL INFORMATION

1A. VETERAN’S NAME

Provide your name in this format: Last name, First name, Middle name

1B. PREFERRED NAME

Provide your preferred name. It is the name to be used instead of your legal first name.

2. MOTHER’S MAIDEN NAME

Enter your mother’s maiden name. A maiden name is the name of a woman before she marries.

3A. BIRTH SEX

Select your gender, either male or female.

3B. SELF-IDENTIFIED GENDER IDENTITY

Choose the gender you identify with, either male or female.

4. SPANISH, HISPANIC, OR LATINO

If you are Spanish, Hispanic or Latino, select YES but if not, select NO.

5. RACE

You may select more than one race among the choices (Asian, American Indian or Alaska Native, Black or African American, Native Hawaiian, or other Pacific Islander, or White), if applicable. This information is used for statistical purposes only.

6. SOCIAL SECURITY NUMBER

Provide your social security number (SSN).

7. VA CLAIM NUMBER

Provide your VA claim number.

8A. DATE OF BIRTH

Enter your date of birth (mm/dd/yyyy).

8B. PLACE OF BIRTH

Provide the city and state only.

9. RELIGION

Enter your religion.

10A. PERMANENT ADDRESS

Enter the street where you permanently live.

10B. CITY

Enter the city where you permanently live.

10C. STATE

Enter the state where you permanently live.

10D. ZIP CODE

Enter the zip code of your permanent address.

10E. COUNTY

Enter the county where you permanently live.

10F. HOME TELEPHONE NUMBER

If applicable, enter your telephone number together with the area code.

10G. MOBILE TELEPHONE NUMBER

If applicable, enter your mobile number together with the area code.

10H. EMAIL ADDRESS

If applicable, enter your email address.

11A. RESIDENTIAL ADDRESS

Provide the street name of your current address where you reside.

11B. CITY

Provide the city name of the current address where you reside.

11C. STATE

Enter the state where you currently reside.

11D. ZIP CODE

Enter the zip code of your current address.

11E. COUNTY

Enter the county of your current address.

12. TYPE OF BENEFIT(S) APPLYING FOR

Choose the benefits you are applying for. You may select more than one.

13. CURRENT MARITAL STATUS

Select your marital status (married, never married, separated, widowed, or divorced).

14A. NEXT OF KIN NAME

Provide the name of your closest family member, it could be your spouse, child, parent, or sibling.

15B. NEXT OF KIN ADDRESS

Enter your kin’s address.

15C. NEXT OF KIN RELATIONSHIP

Enter your relationship with your kin.

14D. NEXT OF KIN TELEPHONE NUMBER

Provide your kin’s telephone number including the area code.

14E. NEXT OF KIN WORK TELEPHONE NUMBER

Provide your kin’s work telephone number including the area code.

15. DESIGNEE

Provide the name of the individual you trust to receive possession of your personal property left on premises under VA control after your departure or at the time of death. This does not let the designee to constitute a will or transfer of title.

16. ENROLLMENT FOR ESSENTIAL COVERAGE

Select YES if you are enrolling to obtain a minimum essential coverage under the affordable care act. Otherwise, select NO.

17. VA MEDICAL CENTER/OUTPATIENT CLINIC PREFERENCE

Provide the medical facility you prefer to have your medical assistance.

18. VA CONTACT PREFERENCE

Mark YES if you would like the VA to contact you to schedule your first appointment. Otherwise, mark NO.

SECTION 2 – MILITARY SERVICE INFORMATION

1A. LAST BRANCH OF SERVICE

Provide the name of the branch where you rendered your last service.

1B. LAST ENTRY DATE

Enter your last duty entry date.

1C. FUTURE DISCHARGE DATE

Enter your future discharge date.

1D. LAST DISCHARGE DATE

Enter your last discharge date.

1E. DISCHARGE TYPE

Indicate your discharge type. Here’s the list of military discharges as follows:

• Indicate your discharge type
• Honorable discharge
• General Discharge Under Honorable Conditions
• Other Than Honorable (OTH) discharge
• Bad Conduct discharge (issued by special court-martial or general court-martial)
• Dishonorable discharge
• Entry-level Separation
• Medical Separation
• Separation for Convenience of the Government

1F. MILITARY SERVICE NUMBER

Indicate your military service number.

2. MILITARY HISTORY

Mark YES or NO for the following questions that match your military history.

• Are you a purple heart award recipient?
• Are you a former prisoner of war?
• Did you serve in a combat theater of operations after 11/11/1998?
• Were you discharged or retired from military for a disability incurred in the line of duty?
• Are you receiving disability retirement pay instead of VA compensation?
• Did you serve in SW Asia during the gulf war between August 2, 1990 and November 11, 1998?
• Do you have a VA service-connected rating? If yes, indicate the percentage rating.
• Did you serve in Vietnam between January 9, 1962 and May 7, 1975?
• Were you exposed to radiation while in the military?
• Did you receive nose and throat radium treatments while in the military?
• Did you serve on active duty at least 30 days at Camp Lejeune from August 1, 1953 through December 31, 1987?

To continue with your application for health benefits, enter your full name and social security number.

SECTION 3 – INSURANCE INFORMATION

Note: You may use a separate spreadsheet for additional information.

1. INSURANCE COMPANY INFORMATION

Provide your insurance company name, address, and telephone number. Then include the coverage for your spouse or other person, if there’s any.

2. NAME OF POLICY HOLDER

Enter the name of the policy holder. It is the person who owns the life insurance.

3. POLICY NUMBER

Provide the policy number.

4. GROUP CODE

Provide the group code.

5. MEDICAID ELIGIBILITY

Mark YES if you are eligible for Medicaid. Otherwise, mark NO.

6A. MEDICARE HOSPITAL INSURANCE PART A

Mark YES if you are enrolled in Medicare Hospital Insurance Part A. Otherwise, mark NO.

6B. EFFECTIVE DATE

If you answered YES in item 6A indicate the effective date in this format: mm/dd/yyyy

SECTION 4 – DEPENDENT INFORMATION

Note: You may use a separate spreadsheet for additional information.

SPOUSE INFORMATION

Provide the necessary information of your spouse.

1. SPOUSE’S NAME

1A. SPOUSE’S SSN

1B. SPOUSE’S DATE OF BIRTH (mm/dd/yyyy)

1C. SPOUSE SELF-IDENTIFIED GENDER IDENTITY

1D. DATE OF MARRIAGE (mm/dd/yyyy)

1E. SPOUSE’S ADDRESS AND TELEPHONE NUMBER
(Street, City, State, ZIP code only if different from Veteran’s)

CHILD’S INFORMATION

Provide the necessary information of your child.

2. CHILD’S NAME

2A. CHILD’S DATE OF BIRTH

2B. CHILD’S SOCIAL SECURITY NUMBER

2C. DATE CHILD BECAME YOUR DEPENDENT (mm/dd/yyyy)

2D. CHILD’S RELATIONSHIP TO YOU. Please choose one.

• Son
• Daughter
• Stepson
• Stepdaughter

Answer the following statements to determine the child’s eligibility:

2E. Was the child permanently and totally disabled before age of 18? YES or NO.

2F. If a child is between 18 and 23 years of age, did the child attend school last calendar year? YES or NO.

2G. Expenses paid by your dependent child for college, vocational rehabilitation or training
(e.g., tuition, books, materials)

3. If your spouse or dependent child did not live with you last year, did you provide support? YES or NO.

SECTION 5 – EMPLOYMENT INFORMATION

1A. VETERAN’S EMPLOYMENT STATUS

Choose one of the following status:

• Full time
• Part time
• Not employed
• Retired

1B. DATE OF RETIREMENT

Indicate your date of retirement.

COMPANY INFORMATION

Complete the information needed if employed or retired.

1C. COMPANY NAME

1D. COMPANY ADDRESS (Street, City, State, ZIP code)

1E. COMPANY PHONE NUMBER (please include area code)

SECTION 6 – PREVIOUS CALENDAR YEAR GROSS ANNUAL INCOME OF VETERAN, SPOUSE AND DEPENDENT CHILDREN

Note: You may use a separate spreadsheet for additional information.

List down your and your Spouse’s and children’s total amount of income for the following categories:

• Gross annual income from employment (wages, bonuses, tips, etc.) excluding income from your farm, ranch, property, or business.
• Net income from your farm, ranch, property, or business.
• List other income amounts (e.g., Social Security, compensation, pension interest, dividends) excluding welfare.

SECTION 7 – PREVIOUS CALENDAR YEAR DEDUCTIBLE EXPENSES

Report the total amount you paid for each category below.

• Total non-reimbursed medical expenses paid by you or your spouse.
• Amount you paid last calendar year for funeral and burial expenses for your deceased spouse or dependent child.

Amount you paid last calendar year for your college or vocational educational expenses.To continue with your application for health benefits, please indicate your full name and social security number.

SECTION 8 – CONSENT TO COPAYS AND TO RECEIVE COMMUNICATIONS

The VA copayments for care or services involve payment as required by law, to which you agree upon submitting this application. You also permit to receive updates and notifications from VA to the contact information you provided. Nevertheless, providing your home phone number, telephone number, or email address is purely voluntary.

How to submit VA Form 10-10EZ?

Please check and review the information you provided before you submit your application to avoid delays. If the form is not signed and dated appropriately, the VA will return it to you for completion

Step 1

You or the individual you have delegated your Power of Attorney must sign and date the form. Signing with an “X,” 2 people should be the eyewitness as you sign the paper. They must sign the form and print their names on the form as well.

Step 2

Attach any continuation sheets, a copy of supporting materials, and the documents of your Power of Attorney for this application.

Step 3

Mail the original application form and supporting documents to the Health Eligibility Center, 2957 Clairmont Road, Suite 200, Atlanta, GA 30329.

Need Help?

You may use any of the following to request assistance and have your questions answered:

• You may ask VA to fill out the form for you by calling 1-877-222-VETS (83877)
• Visit VA’s website and click “Contact the VA.”
• Contact the Enrollment Coordinator at your local VA health care facility.
• You can also contact a National or State Veterans Service Organization.