10-10EZR - revised Health Benefits Update Form

INSTRUCTIONS FOR COMPLETING
HEALTH BENEFITS UPDATE FORM
Please Read Before You Start . . . What is VA Form 10-10EZR used for?

VA Form 10-10EZR is used by VA to update your personal, insurance, or financial information after you are enrolled.

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

This update form is available for completion online at https://www.va.gov/health-care/update-health-information/.
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).
• 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.
TOXIC EXPOSURE RISK ACTIVITY (TERA): Veterans who were exposed to one or more of the following hazards or conditions
during active duty, active duty for training, or inactive duty training (this is not an all-inclusive list): air pollutants, chemicals,
occupational hazards, radiation, and warfare agents. For more information visit https://www.publichealth.va.gov/exposures/.
NONSERVICE-CONNECTED (NSC): A Veteran who does not have a VA determined service-related condition.
REPORTABLE INCOME: The minimum amount of gross income required to file a Federal income tax return according to the
Internal Revenue Code of 1954 Section 6012(a).
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/.

ALL VETERANS MUST COMPLETE SECTIONS I, II, VII, and VIII
Directions for Sections I - II:

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. 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.

Directions for Sections III:

Section III - 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 claiming a Military Exposure, you may provide us a written statement, or
statements from people who witnessed your claimed exposure(s). If you are currently receiving benefits from VA, we will crossreference your information with VA data.

COMPLETE SECTION IV only if you complete Sections V:

Section IV - Dependent Information: Your spouse and dependent social security numbers(s) are required so we can verify
their financial information through a computer-matching program. You may count your spouse as your dependent even if you did not
live together, as long as you contributed support last calendar year. You may count your biological children, adopted children, and
stepchildren as dependents. These children must be unmarried and under the age of 18, or be at least 18 but under 23 and attending
high school, college or vocational school on a full or part-time basis, or have become permanently unable to support themselves
before reaching the age of 18.

Directions for Sections V - VI:

Veterans may provide a financial assessment to update their eligibility for cost-free care or services, beneficiary travel eligibility,
and/or waiver of the beneficiary travel deductible requirement.
Veterans rated 50-100% disabled due to SC conditions and Veterans receiving VA pension are not required to provide a financial
assessment.

Complete only the sections that apply to you; sign and date the form.
VA FORM
JAN 2024

10-10EZR

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Continued ...
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 Compensation 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; lumpsum 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, medications,
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 - Consent to Copays and to Receive Communications.
By submitting this application, you are agreeing to pay the applicable VA copayments for care or services (including urgent care) as
required by law. You also agree to receive communications from VA to your supplied email, home phone number, or mobile
number. However, providing your email, home phone number, or mobile number is voluntary.

Section VIII - Submitting Your Update.
1. Read Paperwork Reduction and Privacy Act Information, Section VI Consent to Copays and Assignment of Benefits.
2. Sign and Date the form. 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 or your Power of Attorney documents to your application.

Where do I mail my update?
Mail the completed VA Form 10-10EZR and any supporting materials to the Health Eligibility Center, PO Box 5207, Janesville, WI
53547-5207.
PAPERWORK REDUCTION ACT AND PRIVACY ACT INFORMATION
Public Burden Statement: An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it
displays a currently valid OMB control number. The OMB control number for this project is 2900-0091, and it expires 6/30/2024. Public reporting
burden for this collection of information is estimated to average 27 minutes per respondent, per year, including the time for reviewing instructions,
searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Send comments
regarding this burden estimate and any other aspect of this collection of information, including suggestions for reducing the burden, to VA Reports
Clearance Officer at VACOPaperworkReduAct@va.gov. Please refer to OMB Control No. 2900-0091 in any correspondence. Do not send your
completed VA Form 10-10EZR to this email address.
Privacy Act Information: VA is asking you to provide the information on this form under 38 U.S.C. Sections 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 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 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.
VA FORM 10-10EZR, JAN 2024

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OMB Control No. 2900-0091
Estimated Burden Avg. 27 min
Expiration Date: 06/30/2024

VA DATE STAMP
(For VHA Use Only)

HEALTH BENEFITS UPDATE FORM
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).
1A. VETERAN'S NAME (Last, First, Middle Name)

2. SOCIAL SECURITY NUMBER

1B. PREFERRED NAME
3A. BIRTH SEX

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

3B. SELF-IDENTIFIED GENDER IDENTITY

MALE

MAN

WOMAN

FEMALE

NON-BINARY

TRANSGENDER MAN

TRANSGENDER WOMAN

PREFER NOT TO ANSWER

5A. HOME TELEPHONE NUMBER (optional)

A GENDER NOT LISTED HERE

5B. MOBILE TELEPHONE NUMBER (optional)

(Include area code)

(Include area code)

6A. MAILING ADDRESS (Street)
6C. STATE

6B. CITY

6D. ZIP CODE

6E. COUNTY

7A. HOME ADDRESS (Street)
7C. STATE

7B. CITY

7D. ZIP CODE

7E. COUNTY

8. E-MAIL ADDRESS (optional)

9. CURRENT MARITAL STATUS
MARRIED

NEVER MARRIED

WIDOWED

DIVORCED

SEPARATED

10A. NEXT OF KIN NAME (Last, First, Middle Name)

10B. NEXT OF KIN ADDRESS

10C. NEXT OF KIN RELATIONSHIP

10D. NEXT OF KIN TELEPHONE NUMBER

11A. EMERGENCY CONTACT NAME

11B. EMERGENCY CONTACT TELEPHONE NUMBER (Include area code)

SECTION II - 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? (Federal

Health Insurance for low income adults)
YES

6A. ARE YOU ENROLLED IN MEDICARE HOSPITAL INSURANCE PART A?
6B. EFFECTIVE DATE (mm/dd/yyyy)

YES

NO

NO

6C. MEDICARE NUMBER:

REMEMBER TO SIGN AND DATE THE FORM ON THE REVERSE PAGE
PREVIOUS EDITIONS OF THIS FORM ARE NOT TO BE USED
VA FORM 10-10EZR, JAN 2024

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HEALTH BENEFITS UPDATE FORM

VETERAN'S NAME (Last, First, Middle)

SOCIAL SECURITY NUMBER

SECTION III - MILITARY SERVICE INFORMATION
1B. LAST ENTRY DATE (mm/dd/yyyy)

1A. LAST BRANCH OF SERVICE

1C. FUTURE DISCHARGE DATE (mm/dd/yyyy)

1E. DISCHARGE TYPE

1D. LAST DISCHARGE DATE (mm/dd/yyyy)

1F. MILITARY SERVICE NUMBER

2. MILITARY HISTORY (Check yes or no)

YES

NO

A. ARE YOU A PURPLE HEART AWARD RECIPIENT?

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

B. ARE YOU A FORMER PRISONER OF WAR?

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

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

F. DO YOU HAVE A VA SERVICE-CONNECTED RATING?

3. MILITARY EXPOSURE INFORMATION (Check yes or no)

YES

NO

NO

YES

NO

D. DID YOU SERVE IN ANY OF THE FOLLOWING HERBICIDE (e.g.
Agent Orange) LOCATIONS? (Republic of Vietnam to include 12

A. DID YOU SERVE IN AN IONIZING RADIATION LOCATION
AND PARTICIPATE IN ANY NUCLEAR TESTING,
TREATMENTS, OR CLEAN UP? (Hiroshima and Nagasaki

nautical mile territorial waters; Thailand at any United States or
Royal Thai base; Laos; Cambodia at Mimot or Krek; Kampong Cham
Province; Guam or American Samoa; or in the territorial waters
thereof; Johnston Atoll or a ship that called at Johnston Atoll;
Korean demilitarized zone; aboard (to include repeated operations
and maintenance with) a c-123 aircraft known to have been used to
spray an herbicide agent (during service in the Air Force and Air
Force Reserves.)

cleanup or Enewetak Atoll, cleanup of Air Force B-52 bomber
carrying nuclear weapons off the coast of Palomares, Spain,
response to the fire onboard an Air Force B-52 bomber
carrying nuclear weapons near Thule Air Force Base in
Greenland.)

B. DID YOU SERVE IN ANY OF THE FOLLOWING GULF WAR
HAZARD LOCATIONS? (Iraq, Kuwait, Saudi Arabia, the

neutral zone between Iraq and Saudi Arabia, Bahrain, Qatar,
the United Arab Emirates, Oman, Yemen, Lebanon, Somalia,
Afghanistan, Israel, Egypt, Turkey, Syria, Jordan, Djibouti,
Uzbekistan, the Gulf of Aden, the Gulf of Oman, the Persian
Gulf, the Arabian Sea, and the Red Sea.)

WHEN DID YOU SERVE IN THESE LOCATIONS?

NOTE: Please provide an approximate time-frame (mm/yyyy)
FROM:

WHEN DID YOU SERVE IN THESE LOCATIONS?

TO:

E. HAVE YOU BEEN EXPOSED TO ANY OF THE FOLLOWING? (Check all that apply)
Veterans can locate additional military exposure categories on VA's Public Health
website at: https://www.publichealth.va.gov/exposures/

NOTE: Please provide an approximate time-frame (mm/yyyy)
FROM:

YES

TO:

AIR POLLUTANTS (burn pits, sand, oil well/sulfur fires)

C. WERE YOU DEPLOYED IN SUPPORT OF ANY OF THE
FOLLOWING OPERATIONS? (Enduring Freedom, Freedom's

CHEMICALS (pesticides, herbicides, contaminated water)

Sentinel, Iraqi Freedom, New Dawn, Inherent Resolve, and
Resolute Support Mission.)

CONTAMINATED WATER AT CAMP LEJEUNE
SHAD (Shipboard Hazard and Defense)

RADIATION

OCCUPATIONAL HAZARDS (jet fuel, industrial solvents, lead, firefighting foams)
ASBESTOS

MUSTARD GAS

WARFARE AGENTS (nerve agents, chemical and biological weapons)
OTHER (Specify):
WHEN WERE YOU EXPOSED?

NOTE: Please provide an approximate time-frame (mm/yyyy)
FROM:

TO:

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

2. SPOUSE'S SOCIAL SECURITY NUMBER
5. DATE OF MARRIAGE (mm/dd/yyyy)

4. SPOUSE'S SELF-IDENTIFIED GENDER IDENTITY
MAN

WOMAN

TRANSGENDER MAN

TRANSGENDER WOMAN

NON-BINARY

PREFER NOT TO ANSWER

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

6. SPOUSE'S ADDRESS AND TELEPHONE NUMBER

(Street, City, State, ZIP - if different from Veteran's)

A GENDER NOT LISTED HERE
7. CHILD'S NAME (Last, First, Middle Name)

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

YES
8. CHILD'S DATE OF BIRTH (mm/dd/yyyy)

9. CHILD'S SOCIAL SECURITY NUMBER

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

DAUGHTER

STEPSON

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

NO

14. EXPENSES PAID BY YOUR DEPENDENT CHILD WITH REPORTABLE
INCOME FOR COLLEGE, VOCATIONAL REHABILITATION OR TRAINING

11. CHILD'S RELATIONSHIP TO YOU (Check one)
SON

NO

STEPDAUGHTER

(e.g., tuition, books, materials)

15. IF YOUR SPOUSE OR DEPENDENT CHILD DID NOT LIVE WITH YOU LAST YEAR, DID YOU PROVIDE SUPPORT?
VA FORM 10-10EZR, JAN 2024

YES

NO
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HEALTH BENEFITS UPDATE FORM

VETERAN'S NAME (Last, First, Middle)

SOCIAL SECURITY NUMBER

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

SPOUSE

CHILD 1

$

$

$

$

$

$

$

$

$

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 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 III.)

$

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.

$

SECTION VII - CONSENT TO COPAYS AND TO RECEIVE COMMUNICATIONS
By submitting this application, you are agreeing to pay the applicable VA copayments for care or services (including urgent care) as required by law. You also
agree to receive communications from VA to your supplied email, home phone number, or mobile number. However, providing your email, home phone number,
or mobile number is voluntary.

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.

SECTION VIII - SUBMITTING YOUR UPDATE
ALL APPLICANTS MUST SIGN AND DATE THIS FORM. REFER TO INSTRUCTIONS WHICH DEFINE WHO CAN SIGN ON BEHALF OF THE
VETERAN.
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).
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:
(Sign in ink)

VA FORM 10-10EZR, JAN 2024

DATE (mm/dd/yyyy):

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