
Where can I get help filling out the form and if I have questions?
ONLY NSC AND 0% NONCOMPENSABLE SC VETERANS MUST COMPLETE THIS SECTION
TO DETERMINE ELIGIBILITY FOR VA HEALTH CARE ENROLLMENT AND/OR CARE OR SERVICES.
Financial Disclosure:
Financial Disclosure Requirements Do Not Apply To:
⢠a former Prisoner of War; or
⢠those in receipt of a Purple Heart; or
⢠a recently discharged Combat Veteran; or
⢠those discharged for a disability incurred or aggravated in the line of duty; or
⢠those receiving VA SC disability compensation; or
⢠those receiving VA pension; or
⢠those in receipt of Medicaid benefits; or
⢠those who served in Vietnam between January 9, 1962 and May 7, 1975; or
⢠those who served in SW Asia during the Gulf War between August 2, 1990 and November 11, 1998; or
⢠those who served at least 30 days at Camp Lejeune between August 1, 1953 and December 31, 1987.
INSTRUCTIONS FOR COMPLETING ENROLLMENT
APPLICATION FOR HEALTH BENEFITS
Getting Started:
Definitions of terms used on this form:
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).
⢠Go to www.va.gov/health-care for information about VA health benefits.
⢠Contact the Enrollment Coordinator at your local VA health care facility.
⢠Contact a National or State Veterans Service Organization.
For Veterans to apply for enrollment in the VA health care system. The information provided on this form will be used by VA to
determine your eligibility for medical benefits and on average will take 30 minutes to complete. This includes the time it will take to
read instructions, gather the necessary facts and fill out the form.
Please Read Before You Start . . . What is VA Form 10-10EZ used for?
⢠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.
⢠COMPENSABLE: A VA determination that a service-connected disability is severe enough to warrant monetary compensation.
⢠NONCOMPENSABLE: A VA determination that a service-connected disability is not severe enough to warrant monetary
compensation.
⢠NONSERVICE-CONNECTED (NSC): A Veteran who does not have a VA determined service-related condition.
Directions for Sections I - III:
Section I - General Information:
Section III - Insurance Information:
Section II - Military Service Information:
Answer all questions.
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.
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.
Directions for Sections IV-VI:
You are not required to disclose your financial information; however, VA is not currently enrolling new applicants who decline to
provide their financial information unless they have other qualifying eligibility factors. If a financial assessment is not used to
determine your priority for enrollment you may choose not to disclose your information. However, if a financial assessment is used
to determine your eligibility for cost-free medication, travel assistance or waiver of the travel deductible, and you do not disclose
your financial information, you will not be eligible for these benefits.
Section IV - Dependent Information: Include the following:
⢠Your spouse even if you did not live together, as long as you contributed support last calendar year.
⢠Your biological children, adopted children, and stepchildren who are unmarried and under the age of 18, or at least 18 but under 23 and
attending high school, college or vocational school (full or part-time), or became permanently unable to support themselves before age 18.
⢠Child support contributions. Contributions can include tuition or clothing payments or payments of medical bills.
ALL VETERANS MUST COMPLETE SECTIONS I - III.
VA FORM
JUL 2021 10-10EZ Complete only the sections that apply to you; sign and date the form. PAGE 1 OF 5HEC