10-334

VA Form - Tribal Documentation Form

Agency: VA
Revision: April 2023
Fillable fields: 14
Pages: 1
Official source: VA form page
Checked: October 20, 2026

VA Form 10-334: Tribal Documentation Form

VA Form 10-334 is the U.S. Department of Veterans Affairs Tribal Documentation Form. VA's form page says to use it to request a copay exemption if you're an eligible American Indian or Alaska Native Veteran. The form says it goes to VA together with a copy of tribal documentation.

The form is one page. It opens with the Paperwork Reduction Act and Privacy Act statements and an Important note citing section 3002 of the Veterans Health Care and Benefits Improvement Act, Public Law 116-315. Section I asks for the Veteran's identification and contact details, signature and date, and fields marked with an asterisk are required. You can fill out the PDF free in your browser on this page and download the result without an account.

Top of page 1 of VA Form 10-334: Tribal Documentation Form, as printed by VA

What's on VA Form 10-334

Notices

OMB Control Number 2900-0920, an estimated burden of 15 minutes, and the Paperwork Reduction Act and Privacy Act statements explaining why VA collects the information.

Important note

The form says that under Public Law 116-315, co-payments for hospital care and medical services received on or after January 5, 2022 are exempted for American Indian and Alaska Native Veterans eligible for VA health care, with this form and tribal documentation provided to VA.

Items 1 to 3E: name and address

Veteran's name and date of birth, both required, then current mailing address, city, state, ZIP code and county.

Items 4 to 7: ID and contact

VA member ID number or Social Security number, which is required, email address, local VA medical center if known, and telephone number with the best time of day to call.

Items 8 and 9: signature and date

The required signature and date, below a statement that Federal law provides criminal penalties for materially false, fictitious, or fraudulent statements (18 U.S.C. 287 and 1001).

How to send VA Form 10-334

1
Fill in Section I
The form says completion of Section I is required to process the request and any omission may delay processing. Fields with an asterisk are required.
2
Make a copy of your tribal documentation
Send a copy, not the original. The form says any items provided will not be returned.
3
Sign and date it
Complete Item 8, signature, and Item 9, date, both marked required.
4
Mail the form and the copy
Mail both to VHA Tribal Documentation, PO Box 5100, Janesville, WI 53547-5100.

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Where to send it and getting help

Mailing address

VHA Tribal Documentation, PO Box 5100, Janesville, WI 53547-5100.

What goes in the envelope

The completed form along with a COPY of the requested tribal documentation. The form says items provided will not be returned.

Questions

The form says to visit www.va.gov/health-care/copay-rates for questions or more information.

Edition

The footer reads VA FORM APR 2023 10-334, matching the April 2023 revision date on VA's form page. OMB Control Number 2900-0920.

Who uses VA Form 10-334?

American Indian and Alaska Native Veterans
VA's page says to use the form to request a copay exemption if you're an eligible American Indian or Alaska Native Veteran, and links to a page on who is eligible.
The Veteran who signs
Item 8 is the signature and Item 9 the date, both marked required.
Tribal documentation
The instructions say to submit the form along with a COPY of the requested tribal documentation, and that items provided will not be returned.
VHA, which receives it
The form goes to VHA Tribal Documentation in Janesville, Wisconsin, and has a VA date stamp box for VHA use only.

VA's form page and the form describe who sends it and who receives it.

Official sources and the blank

Official VA form page
The agency’s own page for Form 10-334.
Blank PDF
The official blank form, to print or fill by hand.

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Questions about Form 10-334

What is VA Form 10-334 used for?

VA's form page says to use it to request a copay exemption if you're an eligible American Indian or Alaska Native Veteran.

What goes with the form?

The instructions say to submit the form along with a COPY of the requested tribal documentation.

Are the documents returned?

No. The form says any items provided will not be returned.

Which fields are required?

The fields marked with an asterisk: the Veteran's name, date of birth, VA member ID number or Social Security number, signature and date.

Which care does the exemption cover?

The form says that under section 3002 of Public Law 116-315, all co-payments for hospital care and medical services received on or after January 5, 2022 are exempted for American Indian and Alaska Native Veterans eligible for VA health care.

Where is VA Form 10-334 mailed?

The form lists VHA Tribal Documentation, PO Box 5100, Janesville, WI 53547-5100.

VA Form 10-334: Tribal Documentation Form