10-10EZ
Instructions and Enrollment Application for Health Benefits
VA Form 10-10EZ is the U.S. Department of Veterans Affairs application Veterans use to apply for enrollment in the VA health care system. VA uses the answers to determine eligibility for medical benefits. VA.gov says a Veteran needs to be enrolled in VA health care to get care at VA health facilities or to have VA cover care at a community care provider, an approved non-VA provider.
The PDF has six pages: three pages of instructions, then the application in Sections I to IX, an Assignment of Benefits and a signature line. The form says all Veterans complete Sections I to III, and the other sections only where they apply. Veterans who already receive VA health care and need to update their details use VA Form 10-10EZR instead.
VA also accepts this application online. You can fill out the PDF free in your browser on this page and download the result without an account.
Enrollment or registration, your name and preferred name, mother's maiden name, sex, race and ethnicity, Social Security number, date and place of birth, mailing and home addresses, marital status, next of kin, emergency contact, a property designee and your preferred VA facility.
Last branch, entry and discharge dates, discharge type and service number. Yes or no questions cover a Purple Heart, prisoner of war status and combat service, then military exposure questions with approximate dates, from radiation and Gulf War locations to herbicides and burn pits.
Your health insurance company, policy holder, policy number and group code, whether you are eligible for Medicaid, and whether you are enrolled in Medicare Part A, with its effective date and number.
Your spouse's and children's names, Social Security numbers, birth dates, marriage date and relationship, plus questions on disability and school attendance. Section V asks your employment status, retirement date and employer's name, address and phone.
A yes or no choice to give household financial information. If yes, last calendar year's gross income from employment, net farm, ranch, property or business income and other income, then non-reimbursed medical, funeral and burial, and your own education expenses.
Consent to copays and to receive communications, the Assignment of Benefits that lets VA bill your health plan for nonservice-connected care, and your signature and date in ink.
The first three pages define terms such as service-connected and compensable, and explain what goes in each section.
Check one benefit type at the top of Section I. The form says all Veterans complete Sections I to III.
The form says to complete only the sections that apply to you. Use a separate sheet for more insurance companies or dependents.
The instructions say a Veteran not yet receiving VA benefits may attach discharge or separation papers, such as a DD-214, to speed processing. Attach continuation sheets, supporting materials and any Power of Attorney documents.
Sign in ink and date the form. If you sign with an X, the form says two people you know witness it, sign and print their names. VA returns a form that is not signed and dated.
Mail the original application and supporting materials to the Health Eligibility Center in Janesville, Wisconsin, or apply online on VA.gov instead.
You get the real form, filled in a browser tab, with nothing standing between you and the finished PDF.
Health Eligibility Center, PO Box 5207, Janesville, WI 53547-5207. Send the original application with your supporting materials.
VA.gov says you can apply online instead of filling out and sending the paper form.
The instructions list calling VA at 1-877-222-VETS (8387), visiting va.gov/health-care, the Enrollment Coordinator at a local VA health care facility, or a National or State Veterans Service Organization.
The form says that by submitting it you agree to pay the applicable VA copayments for care or services, including urgent care, as required by law. The form does not list amounts.
The current edition is dated FEB 2025, and the form says previous editions are not to be used. Its OMB control number is 2900-0091.
10-10d
73 fields, 3 pages
21-526EZ
345 fields, 15 pages
21P-527EZ
477 fields, 17 pages
21-22
63 fields, 4 pages
22-1990
155 fields, 7 pages
The form and its instructions describe who fills in which parts.
No tool matches that search.
Yes. VA.gov says you can apply online instead of filling out and sending the paper VA Form 10-10EZ.
Enrollment is for the VA Medical Benefits Package under 38 CFR 17.36. Registration is for VA health services that the form lists as not needing enrollment, under 38 CFR 17.37. The form says registrants complete only Sections I, II and III.
The form says Veterans are not required to disclose it. It also says VA is not currently enrolling new applicants who decline unless they have other qualifying eligibility factors, and lists groups the financial disclosure requirements do not apply to.
The previous calendar year. Sections VII and VIII ask for last year's gross income and deductible expenses for the Veteran, spouse and dependent children.
The instructions say the Veteran or a person the Veteran has delegated Power of Attorney to signs and dates the form, with the Power of Attorney documents attached. A Veteran who signs with an X needs two witnesses who sign and print their names.
The instructions say Veterans not currently receiving VA benefits may attach a copy of their discharge or separation papers, such as a DD-214 or a WD form for WWII Veterans, to speed processing.
VA.gov points to VA Form 10-10EZR, the Health Benefits Update Form, for Veterans who already receive VA health care and need to update personal, insurance, financial or military service history information.