Updated VA Form 10-10EZR (2022)

VA Health Benefits: Application, Update, Hardship Determination - VA Forms 10-10EZ,10-10EZR and 10-10HS

⚠️ Notice: This information collection may be referencing outdated material.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 10-10EZR Updated VA Form 10-10EZR (2022) Form and Instruction
Form 10-10EZR Updated VA Form 10-10EZR (2022) Form and Instruction
10-10EZR Health Benefits Update Form VA Form 10-10EZR_updated 2022.pdf Form and Instruction
10-10EZR Health Benefits Update Form VA Form 10-10EZR_updated 2022.pdf Form and Instruction
10-10EZR - revised Health Benefits Update Form VA Form 10-10EZR_PACT Act - Sec 103 revisions_JAN 2024_v3.pdf Form and Instruction
10-10EZR - revised Health Benefits Update Form VA Form 10-10EZR_PACT Act - Sec 103 revisions_JAN 2024_v3.pdf Form and Instruction

Information Collection (IC) Details

IC Title:	Updated VA Form 10-10EZR (2022)	Agency IC Tracking Number:	2900-0091

Is this a Common Form? No		IC Status: Modified

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	10-10EZR	Health Benefits Update Form	VA Form 10-10EZR_updated 2022.pdf		Yes	Yes	Fillable Fileable
Form and Instruction	10-10EZR - revised	Health Benefits Update Form	VA Form 10-10EZR_PACT Act - Sec 103 revisions_JAN 2024_v3.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: 859,000	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	Previously Approved
Annual Number of Responses for this IC	859,000	0	859,000
Annual IC Time Burden (Hours)	386,550	42,950	343,600
Annual IC Cost Burden (Dollars)	0	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.