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VA Form 10-10HS: Request for Hardship Determination

VA Form 10-10HS lets a Veteran ask VA for a hardship determination when a drop in income makes health care copays a genuine burden. A granted hardship can change your copay status for future care.

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What is VA Form 10-10HS?

Copay requirements in VA health care are based on the income you reported for a prior year. If your financial situation has worsened since then, because of job loss, retirement, medical bills, or similar events, VA can look at your projected income for the current year instead. VA Form 10-10HS is the request for that review.

The form asks you to compare last year's income with what you expect to earn this year and to explain the circumstances behind the change. If VA grants the hardship, your priority group assignment can change and future copays may be reduced or eliminated for a period. It does not automatically erase debt you already owe, though VA has separate processes for requesting waiver of existing copay debt.

Who files VA Form 10-10HS?

Veterans enrolled in VA health care whose income has dropped significantly since the year VA last assessed
Veterans facing job loss, business loss, retirement, or major out-of-pocket expenses that make copays unaffordable
Veterans whose projected household income for the current year is below VA's applicable thresholds
Caregivers or representatives assisting a Veteran with the financial statements on the form

How to fill out VA Form 10-10HS

Gather records of last year's income and evidence of the change, such as a termination notice or reduced pay statements.
Complete the identifying information and the sections comparing prior-year income with projected current-year income.
Explain the hardship circumstances in the space provided and attach supporting documents.
Sign and date the request.
Submit it to the enrollment or eligibility office at the VA medical center where you receive care; staff there can also answer questions about your copay status.

Quick fill VA Form 10-10HS on this page

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Page 1 20 fields

Read information above. GENERAL INFORMATION. 1. VETERAN'S NAME (Last, First, Middle Name).

3. PERMANENT ADDRESS (Street).

3. A. CITY.

3B. STATE. Enter 2 character abbreviation.

3E. HOME TELEPHONE NUMBER (Include area code).

3F. CELLULAR TELEPHONE NUMBER (Include area code).

Provide explanation, as needed, and attach documentation supporting your request.

3D. COUNTY.

3C. ZIP CODE (9 digits).

REASON / CIRCUMSTANCE FOR HARDSHIP REQUEST (Check all that apply and add explanation as needed below). Reduction of household income.

Moved to a higher cost of living area.

Paid out of pocket medical expenses.

Other - explain below.

Increase in number of dependents.

2. SOCIAL SECURITY NUMBER. Enter 9 digit social security number.

PROJECTED HOUSEHOLD INCOME AND DEDUCTIBLE EXPENSES FOR THE CURRENT CALENDAR YEAR. 1. HOUSEHOLD INCOME (Includes gross income from

2. DEDUCTIBLE EXPENSES. Includes non-reimbursed medical expenses paid by you or your spouse, funeral and burial expenses and expenses for

1. Spouse. Enter dollar amount.

1. Children. Enter dollar amount.

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

Page 2 5 fields

COMMENTS. Document and / or attach any pertinent information impacting on the final decision.

HARDSHIP DETERMINATION (to be completed by V. A.). Hardship Granted (check one). YES. Hardship is granted. Note: The exemption is effective

Date Veteran's electronic record updated in V. A.'s information system. Enter 2 digit month, 2 digit day and 4 digit year.

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

VETERAN NOTIFICATION. Date Veteran notified. Enter 2 digit month, 2 digit day and 4 digit year.

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Frequently asked questions

Will a hardship determination cancel copay debt I already have?

Not by itself. A hardship determination mainly affects your copay status going forward. For existing debt, VA has separate options such as repayment plans, compromise offers, and waiver requests through its debt management processes, including VA Form 5655.

How long does a hardship determination last?

A granted hardship typically applies for a defined period, often through the end of the calendar year, after which VA reassesses your situation. Check with your VA medical center's enrollment office for how it applies to your case.

VA Form 10-10HS: Request for Hardship Determination

What is VA Form 10-10HS?

Who files VA Form 10-10HS?

How to fill out VA Form 10-10HS

Quick fill VA Form 10-10HS on this page

Frequently asked questions

Related forms

VA Form 10-10EZR: Health Benefits Update Form

VA Form 5655: Financial Status Report

VA Form 10-10EZ, Application for Health Benefits