VA · Official form

VA Form 10-10EZ, Application for Health Benefits

VA Form 10-10EZ enrolls veterans in VA health care: eligibility from service history, priority group from disability and income, and coverage from primary care to hospitalization.

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What is VA 10-10EZ?

The 10-10EZ is the VA health care enrollment application. It collects service history, existing insurance including Medicare, dependents, and, for some applicants, a financial assessment that places you in a priority group determining copays. Veterans with service-connected disabilities, recent combat service, or qualifying incomes sit in higher priority groups.

Most veterans with qualifying service can apply any time; the PACT Act expanded eligibility for toxic-exposure era veterans substantially. Applications go online at va.gov, by mail, by phone, or in person at a VA medical center.

Who files VA 10-10EZ?

Veterans with qualifying active service and other-than-dishonorable discharge
Recently separated service members, including within post-service enrollment windows
Veterans with service-connected conditions, exposures, or qualifying income

How to fill out VA 10-10EZ

Complete personal, service, and insurance sections; your DD-214 supplies the service details.
Fill in the financial section unless a listed exemption applies to you.
Note any special eligibility: combat service, exposures, Purple Heart, former POW status.
Download, sign, and mail it to the VA health eligibility center, or apply online at va.gov with the same information.

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Page 4 54 fields

Page 5 44 fields

Page 6 19 fields

SECTION 5 - EMPLOYMENT INFORMATION. 1. A. VETERAN'S EMPLOYMENT STATUS (Check one). FULL TIME.

1B. DATE OF RETIREMENT. Enter 2 digit month, 2 digit day and 4 digit year.

1C. COMPANY NAME. (Complete if employed or retired).

1D. COMPANY ADDRESS (Complete if employed or retired - Street, City, State, ZIP ).

Home Phone Number. Please use digits formatted as (999) 999-9999.

SECTION 6. FINANCIAL DISCLOSURE. Read information above about Disclosure. No, I do not wish to provide financial information in Sections 7

SECTION 5 - PREVIOUS CALENDAR YEAR GROSS ANNUAL INCOME OF VETERAN, SPOUSE AND DEPENDENT CHILDREN (Use a separate sheet for additional

1. SPOUSE GROSS ANNUAL INCOME. Enter dollar amount.

1. CHILD 1 GROSS ANNUAL INCOME. Enter dollar amount.

2. NET INCOME FROM YOUR FARM, RANCH, PROPERTY OR BUSINESS. VETERAN NET INCOME. Enter dollar amount.

2. SPOUSE NET INCOME. Enter dollar amount.

2. CHILD 1 NET INCOME. Enter dollar amount.

3. LIST OTHER INCOME AMOUNTS (e.g., Social Security, compensation, pension, interest, dividends) EXCLUDING WELFARE. VETERAN OTHER INCOME.

3. SPOUSE OTHER INCOME. Enter dollar amount.

3. CHILD 1 OTHER INCOME. Enter dollar amount.

SECTION 8. PREVIOUS CALENDAR YEAR DEDUCTIBLE EXPENSES. 1. TOTAL NON-REIMBURSED MEDICAL EXPENSES PAID BY YOU OR YOUR SPOUSE (e.g., payments

2. AMOUNT YOU PAID LAST CALENDAR YEAR FOR FUNERAL AND BURIAL EXPENSES (INCLUDING PREPAID BURIAL EXPENSES) FOR YOUR DECEASED SPOUSE OR

3. AMOUNT YOU PAID LAST CALENDAR YEAR FOR YOUR COLLEGE OR VOCATIONAL EDUCATIONAL EXPENSES (e.g., tuition, books, fees, materials) DO NOT

DATE OF SIGNATURE. Enter 2 digit month, 2 digit day and 4 digit year.

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Frequently asked questions

Does VA health care cost anything?

Many veterans pay nothing; others pay copays set by priority group. Service-connected care is free, and the financial assessment on this form is what sorts the rest.

Do I need my DD-214 to apply?

It is the cleanest proof of service. If you cannot find it, request it with Standard Form 180 or online, and the VA can often verify service directly in the meantime.

VA Form 10-10EZ, Application for Health Benefits

What is VA 10-10EZ?

Who files VA 10-10EZ?

How to fill out VA 10-10EZ

Quick fill VA 10-10EZ on this page

Frequently asked questions

Related forms

VA Form 21-526EZ, Application for Disability Compensation

Standard Form 180, Request Pertaining to Military Records

VA Form 22-1990, Application for VA Education Benefits