Application for Extended Care Services, VA Form 10-10EC

OMB 2900-0629

Collects information to establish eligibility for extended care benefits, establishes financial liability veteran to pay if accepted for placement in Extended Care Services, and establishes veteran has agreed to make any applicable copayment.

The latest form for Application for Extended Care Services, VA Form 10-10EC expires 2021-06-30 and can be found here.

Latest Forms, Documents, and Supporting Material

Document Name
Form 10-10EC Application for Extended Care Services Form and Instruction
30-day FRN_Application for Extended Care Services_VA Form 10-10EC_2900-0629_published 03092022.pdf Supplementary Document
60-day FRN_Extended Care Services_VA Form 10-10EC_2900-0629_published 12272021.pdf Supplementary Document
Supporting Statement A_Application for Extended Care Services_10-10EC_2900-0629_updated Mar 2022.docx Supporting Statement A
Application for Extended Care Services Form and Instruction

All Historical Document Collections

202107-2900-006 Approved without change	Reinstatement without change of a previously approved collection	2022-03-11
201709-2900-015 Approved without change	Reinstatement with change of a previously approved collection	2018-05-03
201404-2900-011 Approved with change	Revision of a currently approved collection	2014-10-15
201105-2900-005 Approved without change	Extension without change of a currently approved collection	2011-07-27
200801-2900-009 Approved without change	Extension without change of a currently approved collection	2008-06-17
200505-2900-002 Approved without change	Extension without change of a currently approved collection	2005-05-02
200204-2900-008 Approved with change	New collection (Request for a new OMB Control Number)	2002-04-26