VA Form 10-10EZ -- Application for Health Benefits

VA Health Benefits Application and Update - VA Forms 10-10EZ and 10-10EZR

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 2900-0091 can be found here:

Documents and Forms

Document Name Document Type
Form 10-10EZ VA Form 10-10EZ -- Application for Health Benefits Form and Instruction
10-10EZ Application for Health Benefits 10-10EZ.pdf Form and Instruction

Information Collection (IC) Details

IC Title:	VA Form 10-10EZ -- Application for Health Benefits	Agency IC Tracking Number:	2900-0091

Is this a Common Form? No		IC Status: New

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 38 CFR 58.12

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	10-10EZ	Application for Health Benefits	10-10EZ.pdf		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title: 24VA19 Patient Medical Record - VA	FR Citation: 78 FR 17778

Number of Respondents: 500,000	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 25 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	500,000	500,000
Annual IC Time Burden (Hours)	250,000	250,000
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
No associated records found

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.