Where can I get help filling out the form and if I have questions?

Section V - Financial Disclosure: ONLY NSC and 0% NONCOMPENSABLE SERVICE-CONNECTED 

VETERANS MUST COMPLETE THIS SECTION TO DETERMINE ELIGIBILITY AND COPAY 

RESPONSIBILITIES IF THEY ARE NOT:

 

· a former Prisoner of War or; 

· in receipt of a Purple Heart or; 

· a recently discharged Combat Veteran or; 

· discharged for a disability incurred or aggravated in the line of duty or; 

· receiving VA service-connected disability compensation or; 

· receiving VA pension or; 

· in receipt of Medicaid benefits 

 

Failure to provide financial information, if required to do so, may result in denial of VA health care enrollment.

INSTRUCTIONS FOR COMPLETING

APPLICATION FOR HEALTH BENEFITS

Getting Started: 

Definitions of terms used on this form

You may use ANY of the following to request assistance: 

Ask VA to help you fill out the form by calling us at 1-877-222-VETS (8387). 

Access VA's website at http://www.va.gov and select "Contact the VA." 

Contact the Enrollment Coordinator at your local VA health care facility. 

Contact a National or State Veterans Service Organization.

For Veterans to apply for enrollment in the VA health care system, or dental benefits. The information provided on this form 

will be used by VA to determine your eligibility for medical benefits and on average will take 45 minutes to complete. This 

includes the time it will take to read instructions, gather the necessary facts and fill out the form.

Please Read Before You Start . . . What is VA Form 10-10EZ used for?

SERVICE-CONNECTED (SC): A VA determination that an illness or injury was incurred or aggravated in the line of duty, in 

the active military, naval or air service. 

NONCOMPENSABLE: A VA determination that a service-connected disability is not severe enough to warrant monetary 

compensation. 

COMPENSABLE: A VA determination that a service-connected disability is severe enough to warrant monetary 

compensation. 

NONSERVICE-CONNECTED (NSC): A Veteran who does not have a VA determined service-related condition. 

Complete only the sections that apply to you and sign and date the form. VA FORM

NOV 2009 10-10EZ 

ALL VETERANS MUST COMPLETE SECTIONS I - IV.

Directions for Sections I - IV:

Section I - General Information: Answer all questions 

Section II - Insurance Information: Include information for all health insurance companies that cover you, this includes 

coverage provided through a spouse or significant other. Bring your insurance cards, Medicare and/or Medicaid card with you to 

each health care appointment. 

Section III - Employment Information: If you are employed or retired, answer all questions.

Section IV - Military Service Information: If you are not currently receiving benefits from VA, you may attach a copy of 

your discharge or separation papers from the military (such as DD-214 or, for WWII Veterans, a "WD" Form), with your signed 

application to expedite processing of your application. If you are currently receiving benefits from VA, we will cross-reference 

your information with VA data. 

Directions for Sections V - IX:
You are not required to disclose your financial information; however, VA is not currently enrolling new applicants who decline 

to provide their financial information unless they have other qualifying eligibility factors. If a financial assessment is not used to 

determine your priority for enrollment you may choose not to disclose your information and agree to make co-payments for 

treatment of your NSC conditions. If a financial assessment is used to determine your eligibility for cost-free medication, travel 

assistance or waiver of deductible, and you do not disclose your financial information, you may not be eligible for these benefits. 

Additional Information for Completing your application ... 

Answer all questions in the appropriate sections. If you need more space to answer a question, attach a sheet of paper to the form 

containing your name and Social Security Number. If you need more room to respond to a question, write "Continuation of Item" 

and write the section and question number.

Section II - Insurance Information. 

Section IV - Military Service Information. 

Section V - Financial Disclosure.

If you indicate that you received a Purple Heart Medal, we will check our records for confirmation of your status. If we are 

unable to confirm your Purple Heart status, we will ask you to provide VA a copy of your DD-214 or other military service 

records or orders indicating your award. To reduce processing time, you may submit a copy of this documentation with your 

application.

VA FORM

NOV 2009 10-10EZ 

If you are not currently receiving benefits from VA, you may attach a copy of your discharge or separation papers from the 

military (such as DD-214 or, for WWII veterans, a "WD" Form), with your signed application to expedite processing of your 

application.

Include information for all health insurance policies that cover you, this includes coverage that is provided through a spouse or 

significant other. If you have more than one health insurer, provide this information on a separate sheet of paper and attach to the 

application. If you have access to a copier, attach a copy of your insurance cards, Medicare card and/or Medicaid card (Medicaid

is a federal/state health insurance program for certain low-income people). Bring these cards with you to each health care 

appointment. 

Section VI - Dependent Information: Your spouse and dependent social security number(s) are required so we can verify their

financial and insurance information through a computer-matching program.

Section VII - Previous Calendar Year Gross Annual Income of Veteran, Spouse and Dependent Children: Answer 

applicable questions

Section VIII - Previous Calendar Year Deductible Expenses: Answer applicable questions

Section IX - Previous Calendar Year Net Worth: Answer applicable questions

 

NOTE: All other Veterans may wish to provide this financial assessment to determine, as applicable, their eligibility for cost-free 

medication for their NSC conditions, beneficiary travel eligibility and/or waiver of the beneficiary travel deductible requirement. 

Continued ...

Report: 

Gross annual income from employment, except for income from your farm, ranch, property or business. Include your wages, 

bonuses, tips, severance pay and other accrued benefits and your child's income information if it could have been used to pay 

your household expenses. 

Net income from your farm, ranch, property, or business. 

Other income amounts, including retirement and pension income, Social Security Retirement and Social Security Disability 

income, compensation benefits such as VA disability, unemployment, Workers and black lung, cash gifts, interest and 

dividends, including tax exempt earnings and distributions from Individual Retirement Accounts (IRAs) or annuities.

Section VII - Previous Calendar Year Gross Annual Income of Veteran, Spouse and Dependent Children.

Section VI - Dependent Information - Include the following: 

Your spouse even if you did not live together, as long as you contributed support last calendar year. 

Your biological children, adopted children, and stepchildren who are unmarried and under the age of 18, or at least 18 but 

under 23 and attending high school, college or vocational school (full or part-time), or became permanently unable to support 

themselves before age 18. 

Child support contributions. Contributions can include tuition or clothing payments or payments of medical bills. 
NOV 2009 10-10EZ VA FORM

Your net worth is the market value of all the interest and rights you have in any kind of property. However net worth does not 

include your single-family residence and a reasonable lot area surrounding it. It also does not include the personal things you use 

every day like your vehicle, clothing and furniture.

Mail the original application and supporting materials to your local VA health care facility. You can find the address by calling 

VA at 1-877-222-VETS (8387), or on the Internet at http://www.va.gov. 

Section VIII - Previous Calendar Year Deductible Expenses. 

Report non-reimbursed medical expenses paid by you or your spouse. Include expenses for medical and dental care, drugs, 

eyeglasses, Medicare, medical insurance premiums and other health care expenses paid by you for dependents and persons for 

whom you have a legal or moral obligation to support. Do not list expenses if you expect to receive reimbursement from insurance 

or other sources. Report expenses of last illness and burial expenses, e.g., prepaid burial, paid by the veteran for spouse or

dependent(s).

Section IX - Previous Calendar Net Worth. 

Submitting your application.

Read Section X, Paperwork Reduction and Privacy Act Information , Section XI Consent to Copays and Section XII, Assignment 

of Benefits.

In Section XII, you or an individual to whom you have delegated your Power of Attorney must sign and date the form. If you 

sign with an "X", 2 people you know must witness you as you sign. They must sign the form and print their names. If the form is

not signed and dated appropriately, VA will return it for you to complete. 

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

Where do I send my application? 

1.

2.

3.

Donations from public or private relief, welfare or charitable organizations; Supplemental Security Income (SSI)and need-based 

payments from a government agency; profit from the occasional sale of property; income tax refunds, reinvested interest on 

Individual Retirement Accounts (IRAs); scholarships and grants for school attendance; disaster relief payment; reimbursement for

casualty loss; loans; Radiation Compensation Exposure Act payments; Agent Orange settlement payments; Alaska Native Claims 

Settlement Acts Income, payments to foster parent; amounts in joint accounts in banks and similar institutions acquired by reason 

of death of the other joint owner; Japanese ancestry restitution under Public Law 100-383; cash surrender value of life insurance; 

lump-sum proceeds of life insurance policy on a Veteran; and payments received under the Medicare transitional assistance 

program.

Do Not Report: 

Continued ...
 ASIAN

 MALE

 AMERICAN INDIAN OR ALASKA NATIVE

 WHITE NATIVE HAWAIIAN OR OTHER PACIFIC ISLANDER

 BLACK OR AFRICAN AMERICAN YES NO

Federal law provides criminal penalties, including a fine and/or imprisonment for up to 5 years, for concealing a material fact

or making a materially false statement. (See 18 U.S.C. 1001)

5. ARE YOU SPANISH, HISPANIC, OR LATINO?

7. SOCIAL SECURITY NUMBER

10. RELIGION

8. VA CLAIM NUMBER

PAGE 1 VA FORM

NOV 2009 10-10EZ 

APPLICATION FOR HEALTH BENEFITS

1. VETERAN'S NAME (Last, First, Middle Name) 2. OTHER NAMES USED 3. MOTHER'S MAIDEN NAME 4. GENDER 

6. WHAT IS YOUR RACE? (You may check more than one.) (Information is required for statistical purposes only.)

SECTION I - GENERAL INFORMATION

9. DATE OF BIRTH (mm/dd/yyyy)

9A. PLACE OF BIRTH (City and State)

OMB Approved No. 2900-0091

Estimated Burden Avg. 45 min.

FEMALE

16. NAME, ADDRESS AND RELATIONSHIP OF NEXT OF KIN

17. NAME, ADDRESS AND RELATIONSHIP OF EMERGENCY CONTACT (if different than 16)

PREVIOUS EDITIONS OF THIS FORM ARE NOT TO BE USED

16A. NEXT OF KIN'S HOME TELEPHONE NUMBER (Include area code)

16B. NEXT OF KIN'S WORK TELEPHONE NUMBER (Include area code)

17A. EMERGENCY CONTACT'S HOME TELEPHONE NUMBER

(Include area code)

17B. EMERGENCY CONTACT'S WORK TELEPHONE NUMBER 

 (Include area code)

15. CURRENT MARITAL STATUS (Check one) MARRIED NEVER MARRIED SEPARATED WIDOWED DIVORCED UNKNOWN

11G. CELLULAR TELEPHONE NUMBER (Include area code)

11. PERMANENT ADDRESS (Street) 11A. CITY 11C. ZIP CODE 11B. STATE

11D. COUNTY 11E. HOME TELEPHONE NUMBER (Include area code) 11F. E-MAIL ADDRESS

ENROLLMENT/HEALTH SERVICES DENTAL

12. TYPE OF BENEFIT(S) APPLYING FOR 

13. WHICH VA MEDICAL CENTER OR OUTPATIENT CLINIC DO YOU PREFER? 

 (for listing of facilities visit www.va.gov/directory)

 YES NO

14. DO YOU WANT AN APPOINTMENT WITH A VA DOCTOR OR PROVIDER AS SOON 

 AS ONE BECOMES AVAILABLE?

I am only enrolling in case I need care in the future.

(9 digits)

(You may check more than one) 

SECTION II - INSURANCE INFORMATION (Use a separate sheet for additional information)

1. ENTER HEALTH INSURANCE COMPANY NAME, ADDRESS AND TELEPHONE NUMBER (include coverage through spouse or other person)

(mm/dd/yyyy)

(mm/dd/yyyy)

8. NAME EXACTLY AS IT APPEARS ON YOUR MEDICARE CARD 9. MEDICARE CLAIM NUMBER

4. GROUP CODE

YES NO

2. NAME OF POLICY HOLDER 3. POLICY NUMBER 5. ARE YOU ELIGIBLE FOR MEDICAID? 

6A. EFFECTIVE DATE

7A. EFFECTIVE DATE

6 ARE YOU ENROLLED IN MEDICARE HOSPITAL INSURANCE PART A? 

7. ARE YOU ENROLLED IN MEDICARE HOSPITAL INSURANCE PART B?

YES

YES

NO

NO

5A. EFFECTIVE DATE (mm/dd/yyyy)
APPLICATION FOR HEALTH BENEFITS, Continued VETERAN'S NAME (Last, First, Middle) SOCIAL SECURITY NUMBER

PAGE 2 10-10EZ VA FORM

NOV 2009

1A. COMPANY NAME, ADDRESS AND TELEPHONE NUMBER

2A. COMPANY NAME, ADDRESS AND TELEPHONE NUMBER

1. LAST BRANCH OF SERVICE 1A. LAST ENTRY DATE 1B. LAST DISCHARGE DATE 1C. DISCHARGE TYPE 1D. MILITARY SERVICE NUMBER

G. WERE YOU EXPOSED TO RADIATION WHILE IN THE MILITARY?

I. DO YOU HAVE A SPINAL CORD INJURY?

Date of retirement

Date of retirement

If employed or retired, 

complete item 1A

If employed or retired, 

complete item 2A

2. CHECK YES OR NO YES NO YES NO

D. WAS YOUR DISCHARGE FROM MILITARY FOR A DISABILITY INCURRED 

OR AGGRAVATED IN THE LINE OF DUTY?

D1. ARE YOU RECEIVING DISABILITY RETIREMENT PAY INSTEAD OF

VA COMPENSATION?

E. DO YOU NEED CARE OF CONDITIONS POTENTIALLY RELATED TO

SERVICE IN SW ASIA DURING THE GULF WAR?

F. WERE YOU EXPOSED TO AGENT ORANGE WHILE SERVING IN

VIETNAM?

H. DID YOU RECEIVE NOSE AND THROAT RADIUM TREATMENTS

WHILE IN THE MILITARY?

SECTION III - EMPLOYMENT INFORMATION

SECTION IV - MILITARY SERVICE INFORMATION

1. VETERAN'S EMPLOYMENT STATUS

 (Check one)

2. SPOUSE'S EMPLOYMENT 

STATUS (Check one)

FULL TIME

PART TIME

NOT EMPLOYED

RETIRED

FULL TIME

PART TIME

NOT EMPLOYED

RETIRED

A. ARE YOU A PURPLE HEART AWARD RECIPIENT?

(mm/dd/yyyy)

(mm/dd/yyyy)

B. ARE YOU A FORMER PRISONER OF WAR?

C. DID YOU SERVE IN COMBAT AFTER 11/11/1998?

No, I do not wish to provide financial information in Sections VI through IX. I understand that VA is not enrolling new 

applicants who do not provide this information and who do not have other qualifying eligibility factors [i.e., a former Prisoner of 

War; in receipt of a Purple Heart; a recently discharged Combat Veteran (e.g., OEF/OIF who were discharged within the past 5 

years or were discharged more than 5 years ago and applying for enrollment by Jan. 27, 2011); discharged for a disability 

incurred or aggravated in the line of duty; receiving VA service-connected disability compensation; receiving VA pension; or in

receipt of Medicaid benefits.] Sign and date the form in Section XII.

Yes, I will provide my household financial information for last calendar year. Complete applicable sections VI through IX. 

Sign and date the form in Section XII.

Disclosure allows VA to accurately determine whether certain Veterans will be charged copays for care and medications, their 

eligibility for other services and enrollment priority. Veterans are not required to disclose their financial information; however, VA is 

not currently enrolling new applicants who decline to provide their financial information unless they have other qualifying eligibility 

factors. Recent combat Veterans are eligible for enrollment without disclosing their financial information but like other 

Veterans may provide it to establish their eligibility for travel assistance, cost-free medication and/or medical care for services 

unrelated to military experience.

SECTION V - FINANCIAL DISCLOSURE

2F. IF CHILD IS BETWEEN 18 AND 23 YEARS OF AGE, DID CHILD ATTEND SCHOOL LAST

CALENDAR YEAR?

Son Daughter Stepson Stepdaughter

YES NO

YES NO

2B. CHILD'S SOCIAL SECURITY NUMBER 2C. DATE CHILD BECAME YOUR DEPENDENT 

2E. WAS CHILD PERMANENTLY AND TOTALLY DISABLED BEFORE THE AGE OF 18?

3. IF YOUR SPOUSE OR DEPENDENT CHILD DID NOT LIVE WITH YOU LAST YEAR ENTER

THE AMOUNT YOU CONTRIBUTED TO THEIR SUPPORT.

1C. SPOUSE'S DATE OF BIRTH (mm/dd/yyyy) 1D. DATE OF MARRIAGE (mm/dd/yyyy) 2D. CHILD'S DATE OF BIRTH (mm/dd/yyyy)

2A. CHILD'S RELATIONSHIP TO YOU (Check one)

1. SPOUSE'S NAME (Last, First, Middle Name) 2. CHILD'S NAME (Last, First, Middle Name)

1E. SPOUSE'S ADDRESS AND TELEPHONE NUMBER (Street, City, State, ZIP - if different

from Veteran's)

SPOUSE $ CHILD $ $

2G. EXPENSES PAID BY YOUR DEPENDENT CHILD FOR COLLEGE, VOCATIONAL

REHABILITATION OR TRAINING (e.g., tuition, books, materials)

SECTION VI - DEPENDENT INFORMATION (Use a separate sheet for additional dependents)

1A. SPOUSE'S MAIDEN NAME OR OTHER NAMES USED

1B. SPOUSE'S SOCIAL SECURITY NUMBER 

(mm/dd/yyyy)
APPLICATION FOR HEALTH BENEFITS, Continued

SECTION XII - ASSIGNMENT OF BENEFITS

VETERAN'S NAME (Last, First, Middle) SOCIAL SECURITY NUMBER

SIGNATURE OF APPLICANT DATE

VA FORM

NOV 2009 10-10EZ PAGE 3

I understand that pursuant to 38 U.S.C. Section 1729, VA is authorized to recover or collect from my health plan (HP) for 

the reasonable charges of nonservice-connected VA medical care or services furnished or provided to me. I hereby 

authorize payment directly to VA from any HP under which I am covered (including coverage provided under my spouse's HP) that is responsible for payment of the charges for my medical care, including benefits otherwise payable to me or my 

spouse.

ALL APPLICANTS MUST SIGN AND DATE THIS FORM. REFER TO INSTRUCTIONS WHICH DEFINE WHO CAN SIGN ON BEHALF OF THE VETERAN.

SECTION XI - CONSENT TO COPAYS

By signing this application you are agreeing to pay the applicable VA copays for treatment or services of your NSC 

conditions as required by law.

SECTION VIII - PREVIOUS CALENDAR YEAR DEDUCTIBLE EXPENSES

1. TOTAL NON-REIMBURSED MEDICAL EXPENSES PAID BY YOU OR YOUR SPOUSE (e.g., payments for doctors, dentists, medications, Medicare, health

insurance, hospital and nursing home) VA will calculate a deductible and the net medical expenses you may claim.

2. AMOUNT YOU PAID LAST CALENDAR YEAR FOR FUNERAL AND BURIAL EXPENSES (INCLUDING PREPAID BURIAL EXPENSES) FOR YOUR DECEASED

SPOUSE OR DEPENDENT CHILD (Also enter spouse or child's information in Section VI.)

3. AMOUNT YOU PAID LAST CALENDAR YEAR FOR YOUR COLLEGE OR VOCATIONAL EDUCATIONAL EXPENSES (e.g., tuition, books, fees, materials) DO

NOT LIST YOUR DEPENDENTS' EDUCATIONAL EXPENSES. $

$

$

1. GROSS ANNUAL INCOME FROM EMPLOYMENT (wages, bonuses, tips, etc.)

EXCLUDING INCOME FROM YOUR FARM, RANCH, PROPERTY OR BUSINESS 

1. CASH AMOUNT IN BANK ACCOUNTS (e.g., checking, savings accounts, certificates of

deposit, individual retirement accounts, stocks and bonds)

2. MARKET VALUE OF LAND AND BUILDINGS MINUS MORTGAGES AND LIENS. (e.g.,

second home and non-incoming producing property. Do not count your primary home.)

3. VALUE OF OTHER PROPERTY OR ASSETS (e.g., art, rare coins, collectables) MINUS

THE AMOUNT YOU OWE ON THESE ITEMS. INCLUDE VALUE OF FARM, RANCH OR

BUSINESS ASSETS. Exclude household effects and family vehicles.

CHILD 1

CHILD 1

VETERAN

VETERAN

SPOUSE

SPOUSE

$

$

$

$

$

$

$

$

$

$

$$$

$

$

$ $

$

2. NET INCOME FROM YOUR FARM, RANCH, PROPERTY OR BUSINESS 

3. LIST OTHER INCOME AMOUNTS (eg., Social Security, compensation, pension

interest, dividends). EXCLUDING WELFARE. 

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

(Use a separate sheet for additional dependents)

Privacy Act Information: VA is asking you to provide the information on this form under 38 U.S.C. Sections 1705, 

1710, 1712, and 1722 in order for VA to determine your eligibility for medical benefits. Information you supply may be verified through a computer-matching program. VA may disclose the information that you put on the form as permitted 

by law. VA may make a "routine use" disclosure of the information as outlined in the Privacy Act systems of records 

notices and in accordance with the VHA Notice of Privacy Practices. Providing the requested information is voluntary, but if any or all of the requested information is not provided, it may delay or result in denial of your request for health 

care benefits. Failure to furnish the information will not have any effect on any other benefits to which you may be 

entitled. If you provide VA your Social Security Number, VA will use it to administer your VA benefits. VA may also use this information to identify Veterans and persons claiming or receiving VA benefits and their records, and for other 

purposes authorized or required by law. 

The Paperwork Reduction Act of 1995 requires us to notify you that this information collection is in accordance with the

clearance requirements of Section 3507 of the Paperwork Reduction Act of 1995. We may not conduct or sponsor, and you are not required to respond to, a collection of information unless it displays a valid OMB number. We anticipate that

the time expended by all individuals who must complete this form will average 45 minutes. This includes the time it will

take to read instructions, gather the necessary facts and fill out the form.

SECTION X - PAPERWORK REDUCTION ACT AND PRIVACY ACT INFORMATION

SECTION IX - PREVIOUS CALENDAR YEAR NET WORTH (Use a separate sheet for additional dependents)