INSTRUCTIONS FOR COMPLETING
APPLICATION FOR HEALTH BENEFITS
Please Read Before You Start . . . What is VA Form 10-10EZ used for?
For Veterans to apply for enrollment in the VA health care system, or dental benefits. The information provided on this form will be used by VA to determine your eligibility for medical benefits and on average will take 45 minutes to complete. This includes the time it will take to read instructions, gather the necessary facts and fill out the form.

Where can I get help filling out the form and if I have questions?
You may use ANY of the following to request assistance:
• Ask VA to help you fill out the form by calling us at 1-877-222-VETS (8387).
• Access VA's website at http://www.va.gov and select "Contact the VA."
• Contact the Enrollment Coordinator at your local VA health care facility.
• Contact a National or State Veterans Service Organization.

Definitions of terms used on this form
SERVICE-CONNECTED (SC): A VA determination that an illness or injury was incurred or aggravated in the line of duty, in the active military, naval or air service.
NONCOMPENSABLE: A VA determination that a service-connected disability is not severe enough to warrant monetary compensation. COMPENSABLE: A VA determination that a service-connected disability is severe enough to warrant monetary compensation.
NONSERVICE-CONNECTED (NSC): A Veteran who does not have a VA determined service-related condition.

Getting Started:
ALL VETERANS MUST COMPLETE SECTIONS I - IV.
Directions for Sections I - IV:
Section I - General Information: Answer all questions. Note: Veterans determined by a VA clinician to be Catastrophically

Disabled are enrolled in Priority Group 4, unless eligible for a higher Priority Group, and are exempt from inpatient, outpatient and prescription copays. However, these Veterans may still be subject to copayments for extended care (long-term) services.
Section II - Insurance Information: Include information for all health insurance companies that cover you, this includes coverage provided through a spouse or significant other. Bring your insurance cards, Medicare and/or Medicaid card with you to each health care appointment.
Section III - Employment Information: If you are employed or retired, answer all questions.
Section IV - Military Service Information: If you are not currently receiving benefits from VA, you may attach a copy of your discharge or separation papers from the military (such as DD-214 or, for WWII Veterans, a "WD" Form), with your signed application to expedite processing of your application. If you are currently receiving benefits from VA, we will cross-reference your information with VA data.

Directions for Sections V - IX:
Section V - Financial Disclosure: ONLY NSC and 0% NONCOMPENSABLE SERVICE-CONNECTED
VETERANS WHO ARE NOT:
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a former Prisoner of War or; in receipt of a Purple Heart or; a recently discharged Combat Veteran or; discharged for a disability incurred or aggravated in the line of duty or; receiving VA service-connected disability compensation or; receiving VA pension or; in receipt of Medicaid benefits or; determined by VA to be Catastrophically Disabled

MUST COMPLETE THIS SECTION TO DETERMINE ELIGIBILITY AND COPAY RESPONSIBILITY FOR VA health care enrollment and/or care or services. Failure to provide financial information, if required to do so, may result in denial of VA health care enrollment.

VA FORM
FEB 2011

10-10EZ

Complete only the sections that apply to you and sign and date the form.

Continued ...
Section VI - Dependent Information: Your spouse and dependent social security number(s) are required so we can verify their financial and insurance information through a computer-matching program.

Section VII - Previous Calendar Year Gross Annual Income of Veteran, Spouse and Dependent Children: Answer applicable questions

Section VIII - Previous Calendar Year