Instructions, Steps 1 to 4
What to gather before you start, how to complete each section, how to submit and how VA estimates the extended care copayment.
10-10EC
Application for Extended Care Services
- Agency
- VA
- Revision
- May 2025
- Fillable fields
- 62
- Pages
- 4
- Official source
- VA form page
- Checked
- October 20, 2026
VA Form 10-10EC: Application for Extended Care Services
VA Form 10-10EC is the U.S. Department of Veterans Affairs Application for Extended Care Services. The form says it is used to estimate monthly copayment responsibility for extended care services that VA provides directly or pays for. It also says enrollment is required to determine copay responsibility, and that there is no copayment for the first 21 days of extended care services VA provides in any 12-month period.
The PDF has two pages of instructions in four steps, then the application in Sections I to XI: general, insurance and spouse or dependent information, a financial disclosure choice, fixed and liquid assets, current gross income, deductible expenses, consents and the signature. The form estimates 90 minutes to complete.
The completed form goes back to the Veteran's local VA medical facility. You can fill out the PDF free in your browser on this page and download the result without an account.
What's on VA Form 10-10EC
Sections I to III: Veteran, insurance and family
The Veteran's name and Social Security number, whether there is current insurance, one of six marital status choices, and the spouse's and dependents' names, Social Security numbers and dates.
Section IV: Financial disclosure
One checkbox: NO, not providing financial details and assessed the maximum copayment, or YES, providing financial details for the current calendar year.
Sections V and VI: Fixed and liquid assets
Residences, land and vehicles, then cash, bank accounts, stocks, bonds, collectibles and household effects, in Veteran and spouse columns. The form says fixed assets apply only to institutional (inpatient) extended care services after 181+ days.
Sections VII and VIII: Income and expenses
Current gross income from employment, business and other sources, each with how often it is received, then ten deductible expense lines, from education and rent to medical costs and taxes.
Sections IX to XI: Consents and signature
Consent to make copayments, the burden and Privacy Act statements, consent for assignment of benefits to VA from your health plan, and the signature in ink and date.
How to apply with VA Form 10-10EC
- 1
Gather your information
Step 1 lists current income of the Veteran and spouse with how often it is received, deductible expenses, asset values, health insurance and Medicare cards, and spouse and dependent details.
- 2
Complete Sections I to IV
Enter your name and full Social Security number, insurance and family details, and select only one checkbox in Section IV.
- 3
Report assets, income and expenses
Fill in Sections V to VIII. The instructions explain what to report on each line and which figures to exclude, such as spouse figures when legally separated.
- 4
Read the consents
Step 3 asks you to read Section IX, Consent to Agreement to Make Copayments, Section X, the Privacy Act and Paperwork Reduction Act information, and Section XI, Consent for Assignment of Benefits.
- 5
Sign and date Section XI
You or an individual you have delegated Power of Attorney to signs in ink and dates the form.
- 6
Return it to your local VA medical facility
Attach copies of your Medicare and other health insurance cards and any Power of Attorney documents, and return the original form with them.
Why fill Form 10-10EC on indox
You get the real form, filled in a browser tab, with nothing standing between you and the finished PDF.
- Fill the form right in your browser, no software to install
- Free to fill and free to download, with no account
- The official blank straight from the VA, not a copy someone retyped
- Works on a phone, tablet or computer
Where to send it and getting help
Where to return it
The form says to return the original form and supporting documentation to your local VA medical facility. It prints no mailing address.
Help with the form
The form says enrolled Veterans may contact their local VA medical facility for help understanding the information and financial data needed. Administrative staff there are available for copayment questions.
Your copayment estimate
After the information is entered, the form says your local VA medical facility will inform you, or the person you delegated Power of Attorney to, of your estimated monthly copayment for extended care services.
Reporting changes
The form says a Veteran receiving extended care services submits a new 10-10EC to the local VA medical facility within 10 calendar days of a change in marital or dependent status or financials.
Edition
The current edition is dated MAY 2025, and the form says existing stock of the JUN 2021 edition should not be used. It carries OMB Number 2900-0629, which expires 05/31/2028.
Related forms
10-10EZ
Instructions and Enrollment Application for Health Benefits
122 fields, 6 pages
10-10EZR
Health Benefits Update Form
99 fields, 5 pages
10-10HS
Request for Hardship Determination
27 fields, 2 pages
10-10SH
State Home Program Application for Veteran Care Medical Certification
159 fields, 6 pages
10-0137
VA Advance Directive: Durable Power of Attorney for Health Care and Living Will
80 fields, 6 pages
Who uses VA Form 10-10EC?
The instructions describe who completes the form and who handles it.
Official sources and the blank
Do it all with indox
No tool matches that search.
Questions about Form 10-10EC
What is VA Form 10-10EC used for?
The form says it is used to estimate monthly copayment responsibility for extended care services that VA provides directly or pays for.
Is there a copay for the first days of extended care?
The form says there is no copayment for the first 21 days of extended care services that VA provides in any 12-month period. It does not print copayment amounts.
What if I choose not to give financial details?
Section IV says a Veteran who checks NO will be assessed the maximum copayment amount for extended care services and agrees to pay the applicable VA copayment as required by law.
When do the asset sections apply?
The form says fixed and liquid assets are used for the monthly copayment when a Veteran reaches 181+ days of institutional (inpatient) extended care services. Section V is marked N/A for non-institutional care.
Who signs VA Form 10-10EC?
The instructions say you or an individual to whom you have delegated your Power of Attorney signs and dates Section XI.
Where do I send the completed form?
The form says to return the original form and supporting documentation to your local VA medical facility.
Can I use an older edition?
The MAY 2025 form says existing stock of VA Form 10-10EC, JUN 2021, should not be used.