Updated VA Form 10-10EZR (2022)

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

OMB: 2900-0091

IC ID: 256200

Information Collection (IC) Details

View Information Collection (IC)

Updated VA Form 10-10EZR (2022) 2900-0091
 
No Modified
 
Required to Obtain or Retain Benefits
 
38 CFR 58.12

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

Health Health Care Services

24VA19 Patient Medical Record - VA   78 FR 17778

859,000 0
   
Individuals or Households
 
   25 %

  Approved Program Change Due to New Statute Program Change Due to Agency Discretion Change Due to Adjustment in Agency Estimate Change Due to Potential Violation of the PRA Previously Approved
Annual Number of Responses for this IC 859,000 0 0 0 0 859,000
Annual IC Time Burden (Hours) 386,550 0 42,950 0 0 343,600
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

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