Fillable Printable VA Form 10-10EZR
Fillable Printable VA Form 10-10EZR
VA Form 10-10EZR
10-10EZR
VA FORM
APR 2017
Where can I get help filling out the form and if I have questions? This update form is available for
completion online at www.va.gov/healthbenefits.
Veterans may provide a financial assessment to update their eligibility for cost-free medical services for their NSC conditions,
beneficiary travel eligibility, and/or waiver of the beneficiary travel deductible requirement.
INSTRUCTIONS FOR COMPLETING
HEALTH BENEFITS UPDATE FORM
Definitions of terms used on this form:
VA Form 10-10EZR is used by VA to update your personal, insurance, or financial information after you are enrolled.
Please Read Before You Start . . . What is VA Form 10-10EZR used for?
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.
NONSERVICE-CONNECTED (NSC): A Veteran who does not have a VA determined service-related condition.
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/.
Complete only the sections that apply to you; sign and date the form.
ALL VETERANS MUST COMPLETE SECTIONS I, II, VI, and VII
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 IV - V:
Section III - 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.
COMPLETE SECTION III only if you complete Sections IV:
Veterans rated 50-100% disabled due to SC conditions and Veterans receiving VA pension are not required to provide a financial
assessment.
• 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.
You may use ANY of the following to request assistance:
10-10EZR
VA FORM
APR 2017
PAPERWORK REDUCTION ACT AND PRIVACY ACT INFORMATION
Continued ...
Section IV - Previous Calendar Year Gross Annual Income of Veteran, Spouse and Dependent Children.
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; lump-
sum proceeds of life insurance policy on a Veteran; and payments received under the Medicare transitional assistance program.
Section V - 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 VI and Section VII - Submitting your update.
Where do I mail my update?
Mail the completed VA Form 10-10EZR and any supporting materials to the Health Eligibility Center, 2957 Clairmont Road, Suite
200, Atlanta, GA 30329.
The Paperwork Reduction Act of 1995 requires us to notify you that this information collection is in accordance with the clearance
requirements of Section 3507 of the Paperwork Reduction Act of 1995. We may not conduct or sponsor, and you are not required to
respond to, a collection of information unless it displays a valid OMB number. We anticipate that the time expended by all individuals
who must complete this form will average 15 minutes. This includes the time it will take to read instructions, gather the necessary facts
and fill out the form.
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.
1. Read Paperwork Reduction and Privacy Act Information, Section VII 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.
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.
10-10EZR
VA FORM
APR 2017
SECTION III - DEPENDENT INFORMATION (Use a separate sheet for additional dependents)
SECTION I - GENERAL INFORMATION
SECTION II - INSURANCE INFORMATION (Use a separate sheet for additional 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).
2. SOCIAL SECURITY NUMBER
PAGE 1
HEALTH BENEFITS UPDATE FORM
1A. VETERAN'S NAME (Last, First, Middle Name)
3A. BIRTH SEX 3B. SELF-IDENTIFIED GENDER IDENTITY
4. DATE OF BIRTH (mm/dd/yyyy)
OMB Approved No. 2900-0091
Estimated Burden Avg. 15 min
Expiration Date: 01/17/2017
PREVIOUS EDITIONS OF THIS FORM ARE NOT TO BE USED
6. MOBILE TELEPHONE NUMBER (Include area code)
8A. RESIDENTIAL ADDRESS (Street)
8B. CITY
8E. COUNTY8D. ZIP CODE 8C. STATE
7C. STATE
7B. CITY
7D. ZIP CODE
7A. PERMANENT ADDRESS (Street)
9. E-MAIL ADDRESS
7E. COUNTY
5. HOME TELEPHONE NUMBER
(Include area code)
1. ENTER YOUR HEALTH INSURANCE COMPANY NAME, ADDRESS AND TELEPHONE NUMBER (include coverage through spouse or other person)
4. GROUP CODE2. NAME OF POLICY HOLDER 3. POLICY NUMBER
5. ARE YOU ELIGIBLE
FOR MEDICAID?
6. ARE YOU ENROLLED IN MEDICARE HOSPITAL INSURANCE PART A?
10. CURRENT MARITAL STATUS
1B. VETERAN'S PREFERRED NAME (Last, First, Middle Name)
MALE
FEMALE
MALE
FEMALE
MARRIED NEVER MARRIED SEPARATED
WIDOWED DIVORCED
YES NO
YES NO
13. IF CHILD IS BETWEEN 18 AND 23 YEARS OF AGE, DID CHILD ATTEND
SCHOOL LAST CALENDAR YEAR?
9. CHILD'S SOCIAL SECURITY NUMBER
10. DATE CHILD BECAME YOUR DEPENDENT
(mm/dd/yyyy)
12. WAS CHILD PERMANENTLY AND TOTALLY DISABLED BEFORE THE AGE OF 18?
15. IF YOUR SPOUSE OR DEPENDENT CHILD DID NOT LIVE WITH YOU LAST YEAR, DID YOU PROVIDE SUPPORT?
3. SPOUSE'S DATE OF BIRTH (mm/dd/yyyy)
5. DATE OF MARRIAGE (mm/dd/yyyy)
8. CHILD'S DATE OF BIRTH (mm/dd/yyyy)
11. CHILD'S RELATIONSHIP TO YOU (Check one)
1. SPOUSE'S NAME (Last, First, Middle Name)
7. CHILD'S NAME (Last, First, Middle Name)
6. SPOUSE'S ADDRESS AND TELEPHONE NUMBER
(Street, City, State, ZIP - if different from Veteran's)
14. EXPENSES PAID BY YOU FOR YOUR DEPENDENT CHILD FOR COLLEGE,
VOCATIONAL REHABILITATION OR TRAINING
(e.g., tuition, books, materials)
2. SPOUSE'S SOCIAL SECURITY NUMBER
STEPDAUGHTER
YES NO
YES NO
YES NO
STEPSONDAUGHTER SON
REMEMBER TO SIGN AND DATE THE FORM ON THE REVERSE PAGE
7. EFFECTIVE DATE (mm/dd/yyyy)
FEMALE MALE
4. SPOUSE'S SELF-IDENTIFIED GENDER IDENTITY
10-10EZR
VA FORM
APR 2017
SECTION VII - SUBMITTING YOUR UPDATE
ASSIGNMENT OF BENEFITS
SECTION VI - CONSENT TO COPAYS AND TO RECEIVE COMMUNICATIONS
SECTION V - PREVIOUS CALENDAR YEAR DEDUCTIBLE EXPENSES
HEALTH BENEFITS UPDATE FORM
VETERAN'S NAME (Last, First, Middle)
SOCIAL SECURITY NUMBER
PAGE 2
SECTION IV - PREVIOUS CALENDAR YEAR GROSS ANNUAL INCOME OF VETERAN, SPOUSE AND DEPENDENT CHILDREN
(Use a separate sheet for additional dependents)
VETERAN SPOUSE CHILD 1
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.
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.
$
$
$
$
$
$
$
$
$ $
$
$
By submitting this application you are agreeing to pay the applicable VA copays for treatment or services of your NSC conditions as required by law. You also
agree to receive communications from VA to your supplied email or mobile number.
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.
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).
l 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)
DATE:
