Form 10-10EZ, Instructions and Enrollment Application for Health Benefits

What is 10-10EZ?

Who needs to file 10-10EZ?

When to file 10-10EZ

Documents you need

• Copy of discharge or separation papers (such as DD-214 or, for WWII Veterans, a "WD" Form): optional, for Veterans not currently receiving VA benefits, to expedite processing.
• Written statement, or statements from people who witnessed it, supporting a claimed Military Exposure: you may provide it if you answer yes to an exposure question in Section II.
• Continuation sheets: attach them when you need more space, for example for additional insurance, dependents or income entries.
• Copies of supporting materials: attach them to the signed application when mailing it.
• Power of Attorney documents: attach them if someone you have delegated Power of Attorney signs the form for you.
• Insurance, Medicare and Medicaid cards: do not mail them; the instructions say to bring them to each health care appointment.

How to fill out 10-10EZ

1. 1

   Choose enrollment or registration

   In Section I, check Enrollment for the VA Medical Benefits Package or Registration if you meet the "Enrollment not required" criteria. Registration applicants complete only Sections I, II and III.

2. 2

   Enter your personal details

   Section I, items 1A to 8: name, preferred name, mother's maiden name, sex, race/ethnicity (statistical purposes only), Social Security number as 999-99-9999, date of birth as MM/DD/YYYY, place of birth, preferred language and religion.

3. 3

   Enter addresses, phones and marital status

   Items 9A to 9H are your mailing address, county, home and mobile telephone numbers and email; the phone and email entries are optional. Items 10A to 10E are your home address and item 11 is your marital status.

4. 4

   Add contacts and facility preference

   Items 12A to 12D are next of kin, 13A and 13B an emergency contact, and item 14 the designee for your personal property left under VA control. Items 15 and 16 give your preferred VA medical center or clinic and whether VA should contact you to schedule your first appointment.

5. 5

   Complete military service information

   Section II, items 1A to 1F: last branch of service, last entry date, future and last discharge dates in MM/DD/YYYY, discharge type and service number. Then answer yes or no to the military history questions 2A to 2F.

6. 6

   Answer military exposure questions

   Section II, item 3: answer 3A to 3D and check all that apply under 3E. Give an approximate time-frame in MM/YYYY where the form asks FROM and TO.

7. 7

   List your insurance

   Section III: enter each health insurance company's name, address and telephone number, the policy holder, policy number and group code, whether you are eligible for Medicaid, and your Medicare Part A status with effective date and number. Use a separate sheet for more.

8. 8

   Add spouse and dependent children

   Section IV: enter your spouse in items 1 to 1E and each child in items 2 to 2G, and answer item 3 about support if they did not live with you. Use a separate sheet for additional dependents.

9. 9

   Enter employment information

   Section V: check your employment status in 1A, give the retirement date in 1B if retired, and complete company name, address and phone in 1C to 1E only if employed or retired.

10. 10

    Decide on financial disclosure

    In Section VI, check whether you will provide household financial information. If yes, complete Section VII (previous calendar year gross income of you, your spouse and children) and Section VIII (deductible expenses).

11. 11

    Read the consent and assignment

    Section IX states that submitting the application means agreeing to pay the applicable VA copayments and to receive VA communications. Read the Assignment of Benefits statement above the signature line.

12. 12

    Review, sign and download the PDF

    Check each section, then sign and date the Signature of Applicant box in MM/DD/YYYY format; the form says to sign in ink. Download or print the completed PDF from FillingPDF and submit it as described under How to submit.

How to submit 10-10EZ

Common mistakes to avoid

• Submitting the form unsigned or undated; VA returns it for you to complete.
• Signing with an "X" without two people you know witnessing, signing and printing their names.
• Completing Sections IV through IX when you only need Registration; that path requires only Sections I, II and III.
• Leaving out insurance coverage held through a spouse or significant other; Section III asks for all health insurance companies that cover you.
• Listing a spouse or child only if they lived with you; the instructions include a spouse you supported last calendar year and children you provided support for.
• Reporting income that the instructions say not to report, such as SSI, income tax refunds, scholarships and grants, or disaster relief payments.
• Listing medical expenses that you expect to be reimbursed by insurance or other sources in Section VIII.
• Mailing the application to the [email protected] address; the instructions say not to send the completed form there.
• Using a previous edition of the form; the form states that previous editions are not to be used.