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tÉlÉcharger va form 10-10ez pdf

INSTRUCTIONS FOR COMPLETING ENROLLMENT APPLICATION FOR HEALTH BENEFITS
Please Read Before You Start . . . What is VA Form 10-10EZ used for?
For Veterans to apply for enrollment in the VA health care system. The information provided on this form will be used by VA
to determine your eligibility for medical benefits and on average will take 30 minutes to complete. This includes the time it
will take to read instructions, gather the necessary facts and fill out the form.
Where can I get help filling out the form and if I have questions?
You may use ANY of the following to request assistance:
• Ask VA to help you fill out the form by calling us at 1-877-222-VETS (8387).
• Access VA's website at http://www.va.gov and select "Contact the VA."
• Contact the Enrollment Coordinator at your local VA health care facility.
• Contact a National or State Veterans Service Organization.
Definitions of terms used on this form:
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.
Getting Started:
ALL VETERANS MUST COMPLETE SECTIONS I - III.
Directions for Sections I - III:
Section I - General Information: Answer all questions.
Section II - Military Service Information: If you are not currently receiving benefits from VA, you may attach a copy of
your discharge or separation papers from the military (such as DD-214 or, for WWII Veterans, a "WD" Form), with your
signed application to expedite processing of your application. If you are currently receiving benefits from VA, we will crossreference your information with VA data.
Section III - Insurance Information: Include information for all health insurance companies that cover you, this includes
coverage provided through a spouse or significant other. Bring your insurance cards, Medicare and/or Medicaid card with you
to each health care appointment.
Directions for Sections IV-VI:
Financial Disclosure: ONLY NSC AND 0% NONCOMPENSABLE SC VETERANS MUST COMPLETE THIS
SECTION TO DETERMINE ELIGIBILITY AND COPAY RESPONSIBILITY FOR VA HEALTH CARE ENROLLMENT
AND/OR CARE OR SERVICES.
Financial Disclosure Requirements Do Not Apply To:










a former Prisoner of War; or
those in receipt of a Purple Heart; or
a recently discharged Combat Veteran; or
those discharged for a disability incurred or aggravated in the line of duty; or
those receiving VA SC disability compensation; or
those receiving VA pension; or
those in receipt of Medicaid benefits; or
those who served in Vietnam between January 9, 1962 and May 7, 1975; or
those who served in SW Asia during the Gulf War between August 2, 1990 and November 11, 1998; or
those who served at least 30 days at Camp Lejeune between August 1, 1953 and December 31, 1987.
You are not required to disclose your financial information; however, VA is not currently enrolling new applicants who decline to
provide their financial information unless they have other qualifying eligibility factors. If a financial assessment is not used to
determine your priority for enrollment you may choose not to disclose your information. However, if a financial assessment is used
to determine your eligibility for cost-free medication, travel assistance or waiver of the travel deductible, and you do not disclose
your financial information, you will not be eligible for these benefits.
VA FORM
APR 2017
10-10EZ
Complete only the sections that apply to you; sign and date the form.
Continued ...
Section IV - Dependent Information: Include the following:
• Your spouse even if you did not live together, as long as you contributed support last calendar year.
• Your biological children, adopted children, and stepchildren who are unmarried and under the age of 18, or at least 18 but under

23 and attending high school, college or vocational school (full or part-time), or became permanently unable to support
themselves before age 18.
Child support contributions. Contributions can include tuition or clothing payments or payments of medical bills.
Section V - Previous Calendar Year Gross Annual Income of Veteran, Spouse and Dependent Children.
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 and black lung, cash gifts, interest and dividends,
including tax exempt earnings and distributions from Individual Retirement Accounts (IRAs) or annuities.
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 VI - Previous Calendar Year Deductible Expenses.
Report non-reimbursed medical expenses paid by you or your spouse. Include expenses for medical and dental care, drugs,
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 VII - Submitting your application.
1. 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.
2. Attach any continuation sheets, a copy of supporting materials and your Power of Attorney documents to your application.