Form 10-10EZ Enrollment Application for Health Benefits

INSTRUCTIONS FOR COMPLETING ENROLLMENT APPLICATION FOR HEALTH BENEFITS
Please Read Before You Start . . . What is VA Form 10-10EZ used for?
For Veterans to apply for enrollment in the VA health care system. The information provided on this form will be used by VA to determine your
eligibility for medical benefits and on average will take 30 minutes to complete. This includes the time it will take to read instructions, gather the
necessary facts and fill out the form.

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

Definitions of terms used on this form:
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.
COMPENSABLE: A VA determination that a service-connected disability is severe enough to warrant monetary compensation.
NONCOMPENSABLE: A VA determination that a service-connected disability is not severe enough to warrant monetary
compensation.
NONSERVICE-CONNECTED (NSC): A Veteran who does not have a VA determined service-related condition.
SPOUSE: If you are certifying that a person is your spouse for the purpose of VA benefits, your marriage must be recognized by the place where you
and/or your spouse resided at the time of marriage, or where you and/or your spouse reside when you file your claim (or at a later date when you become
eligible for benefits) (38 U.S.C. 103(c)). Additional guidance on when VA recognizes marriages is available at http://www.va.gov/opa/marriage/.

Getting Started:

ALL VETERANS MUST COMPLETE SECTIONS I - III.
Directions for Sections I - III:

Section I - General Information: Answer all questions.
Section II - 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.
Section III - 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.

Directions for Sections IV - VII:
Financial Disclosure: ONLY NSC AND 0% NONCOMPENSABLE SC VETERANS MUST COMPLETE THIS SECTION
TO DETERMINE ELIGIBILITY AND COPAY RESPONSIBILITY FOR VA HEALTH CARE ENROLLMENT AND/OR
CARE OR SERVICES.
Financial Disclosure Requirements Do Not Apply To:
• a former Prisoner of War; or
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those in receipt of a Purple Heart; or
a recently discharged Combat Veteran; or
those discharged for a disability incurred or aggravated in the line of duty; or
those receiving VA SC disability compensation; or
those receiving VA pension; or
those in receipt of Medicaid benefits; or
those who served in Vietnam between January 9, 1962 and May 7, 1975; or
those who served in SW Asia during the Gulf War between August 2, 1990 and November 11, 1998; or
those who served at least 30 days at Camp Lejeune between January 1, 1957 and December 31, 1987.

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. However, if a financial assessment is used to determine your eligibility for cost-free
medication, travel assistance or waiver of the travel deductible, and you do not disclose your financial information, you will not be eligible for these
benefits.

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

Continued ...
Section IV - 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.

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

Do Not Report:

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 payments; 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.

Section VI - 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 last illness and burial
expenses, e.g., prepaid burial, paid by the Veteran for spouse or dependent(s).

Section VII - Previous Calendar Year Net Worth.

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 singlefamily 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.

Section VIII - Submitting your application.

1. Read Paperwork Reduction and Privacy Act Information, Section VIII, Consent to Copays and Assignment of Benefits.
2. In Section VIII, 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.

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

Where do I send my application?
Mail the original application and supporting materials to the Health Eligibility Center, 2957 Clairmont Road, Suite 200, Atlanta, GA 30329.
PAPERWORK REDUCTION ACT AND PRIVACY ACT INFORMATION

The Paperwork Reduction Act of 1995 requires us to notify you that this information collection is in accordance with
clearance requirements of Section 3507 of the Paperwork Reduction Act of 1995. We
may not conduct or sponsor,
you are not required to respond to, a collection of information unless it displays a valid OMB number. We anticipate
the time expended by all individuals who must complete this form will average 30 minutes. This includes the time it
take to read instructions, gather the necessary facts and fill out the form.

the
and
that
will

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 from initial submission forward through a computermatching 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.

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OMB Approved No. 2900-0091
Estimated Burden Avg. 30 min.
Expiration Date xx/xx/xxxx

APPLICATION FOR HEALTH BENEFITS
SECTION I - GENERAL INFORMATION

Federal law provides criminal penalties, including a fine and/or imprisonment, for any materially false, fictitious, or
fraudulent statement or representation. (See 18 U.S.C. 287 and 1001).
1. VETERAN'S NAME (Last, First, Middle Name)

2. MOTHER'S MAIDEN NAME

3. GENDER

MALE
4. ARE YOU SPANISH, HISPANIC, OR LATINO?

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

YES

AMERICAN INDIAN OR ALASKA NATIVE

BLACK OR AFRICAN AMERICAN

NO

ASIAN

NATIVE AMERICAN OR OTHER PACIFIC ISLANDER

WHITE

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

6. SOCIAL SECURITY NUMBER

8. PERMANENT ADDRESS (Street)

7A. PLACE OF BIRTH (City and State)

8A. CITY

8B. STATE

8G. E-MAIL ADDRESS

8C. ZIP CODE

8F. MOBILE TELEPHONE NUMBER (Include area code)

8E. HOME TELEPHONE NUMBER (Include area code)

8D. COUNTY

9. CURRENT MARTIAL STATUS

NEVER MARRIED

MARRIED
10. I AM ENROLLING TO OBTAIN MINIMUM ESSENTIAL COVERAGE
UNDER THE AFFORDABLE CARE ACT

YES

FEMALE

SEPARATED

WIDOWED

DIVORCED

12. WOULD YOU LIKE FOR VA TO
CONTACT YOU TO SCHEDULE
YOUR FIRST APPOINTMENT?

11. WHICH VA MEDICAL CENTER OR OUTPATIENT CLINIC DO YOU
PREFER? (for listing of facilities visit www.va.gov/directory)

NO

YES

NO

SECTION II - MILITARY SERVICE INFORMATION
1. LAST BRANCH OF SERVICE

1A. LAST ENTRY DATE

2. MILITARY HISTORY (Check yes or no)

1B. LAST DISCHARGE DATE

YES

1C. DISCHARGE TYPE

YES

NO

A. ARE YOU A PURPLE HEART AWARD RECIPIENT?

E. DID YOU SERVE IN SW ASIA DURING THE GULF WAR BETWEEN
AUGUST 2, 1990 AND NOVEMBER 11, 1998?

B. ARE YOU A FORMER PRISONER OF WAR?

F. DID YOU SERVE IN VIETNAM BETWEEN JANUARY 9, 1962 AND MAY 7,
1975?

C. DID YOU SERVE IN A COMBAT THEATER OF OPERATIONS AFTER 11/11/1998?

NO

G. WERE YOU EXPOSED TO RADIATION WHILE IN THE MILITARY?
H. DID YOU RECEIVE NOSE AND THROAT RADIUM TREATMENTS WHILE
IN THE MILITARY?

D. WERE YOU DISCHARGED OR RETIRED FROM MILITARY FOR A DISABILITY
INCURRED IN THE LINE OF DUTY?

I. DID YOU SERVE ON ACTIVE DUTY AT LEAST 30 DAYS AT
CAMP LEJEUNE FROM JANUARY 1, 1957 THROUGH DECEMBER 31, 1987?

SECTION III - INSURANCE INFORMATION (Use a separate sheet for additional information)
1. ENTER YOUR HEALTH INSURANCE COMPANY NAME, ADDRESS AND TELEPHONE NUMBER (include coverage through spouse or other person)

2. NAME OF POLICY HOLDER

3. POLICY NUMBER

4. GROUP CODE

5. ARE YOU ELIGIBLE
FOR MEDICAID?

YES
NO

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6. ARE YOU ENROLLED IN MEDICARE HOSPITAL INSURANCE PART A?

YES

NO

6A. EFFECTIVE DATE (mm/dd/yyyy)

PREVIOUS EDITIONS OF THIS FORM ARE NOT TO BE USED

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VETERAN'S NAME (Last, First, Middle)

APPLICATION FOR HEALTH BENEFITS, Continued

SOCIAL SECURITY NUMBER

SECTION IV - DEPENDENT INFORMATION (Use a separate sheet for additional dependents)
1. SPOUSE'S NAME (Last, First, Middle Name)

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

1A. SPOUSE'S SOCIAL SECURITY NUMBER

2A. CHILD'S DATE OF BIRTH (mm/dd/yyyy)

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

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

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

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

SON

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

DAUGHTER

2B. CHILD'S SOCIAL SECURITY NUMBER

STEPSON

STEPDAUGHTER

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

YES

from Veteran's)

NO

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

YES
3. IF YOUR SPOUSE OR DEPENDENT CHILD DID NOT LIVE WITH YOU LAST YEAR, DID
YOU PROVIDE SUPPORT?

YES

NO

2G. EXPENSES PAID BY YOUR DEPENDENT CHILD FOR COLLEGE, VOCATIONAL
REHABILITATION OR TRAINING (e.g., tuition, books, materials)

NO

SECTION V - PREVIOUS CALENDAR YEAR GROSS ANNUAL INCOME OF VETERAN, SPOUSE AND DEPENDENT CHILDREN
(Use a separate sheet for additional dependents)
VETERAN

SPOUSE

CHILD 1

1. GROSS ANNUAL INCOME FROM EMPLOYMENT (wages, bonuses, 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 AMOUNTS (e.g., Social Security, compensation, pension
interest, dividends) EXCLUDING WELFARE.

SECTION VI - 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

$

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)

$

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

DO NOT LIST YOUR DEPENDENTS' EDUCATIONAL EXPENSES.

SECTION VII - PREVIOUS CALENDAR YEAR NETWORTH (Use a separate sheet for additional dependents)
VETERAN
1. CASH AMOUNT IN BANK ACCOUNTS (e.g., checking, savings accounts, certificates of deposit,

SPOUSE

CHILD 1

$

$

$

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

$

$

$

individual retirement accounts, stocks and bonds)

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

household effects and family vehicles.

SECTION VIII - CONSENT TO COPAYS AND TO RECEIVE COMMUNICATIONS
By submitting this application you are agreeing to pay the applicable VA copays for treatment or services of your NSC conditions as required by law. You also
agree to receive communications from VA to your supplied email or mobile number.
ASSIGNMENT OF BENEFITS
I understand that pursuant to 38 U.S.C. Section 1729 and 42 U.S.C. 2651, the Department of Veterans Affairs (VA) is authorized to recover or collect from my health plan
(HP) or any other legally responsible third party 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. Furthermore, I hereby assign to the VA any claim I may have against any person or
entity who is or may be legally responsible for the payment of the cost of medical services provided to me by the VA. I understand that this assignment shall not limit or
prejudice my right to recover for my own benefit any amount in excess of the cost of medical services provided to me by the VA or any other amount to which I may be
entitled. I hereby appoint the Attorney General of the United States and the Secretary of Veterans' Affairs and their designees as my Attorneys-in-fact to take all necessary
and appropriate actions in order to recover and receive all or part of the amount herein assigned. I hereby authorize the VA to disclose, to my attorney and to any third
party or administrative agency who may be responsible for payment of the cost of medical services provided to me, information from my medical records as necessary to
verify my claim. Further, I hereby authorize any such third party or administrative agency to disclose to the VA any information regarding my claim.
I declare under penalty of perjury that the foregoing is true and accurate to the best of my knowledge. I understand that any materially false, fictitious, or fraudulent
statement or representation, made knowingly, is punishable by a fine and/or imprisonment pursuant to title 18, United States Code, Sections 287 and 1001.

SIGNATURE OF APPLICANT
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