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Step 1: Before You Start . . . What is VA Form 10-10EZ used for? - page 1 / 5

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INSTRUCTIONS FOR COMPLETING APPLICATION FOR HEALTH BENEFITS

Step 1: Before You Start . . . What is VA Form 10-10EZ used for?

To apply for enrollment in the VA health care system, or for nursing home, domiciliary or dental benefits. Where can I get help filling out the form?

Contact a National or State Veterans Service Organization. Ask VA to help you fill out the form by calling or visiting a VA health care facility. Before you call or go to the VA health care

facility, gather the necessary materials identified in Step 2 of the instructions and complete as much of the form as you can. How can I contact VA if I have questions?

Look in your telephone book blue pages under "United States Government, Veterans" to locate your local VA health care facility. Call VA's Health Benefits Service Center toll-free at 1-877-222-VETS (8387).

Access our website at http://www.va.gov and select "Contact the VA." If you desire a health care appointment, contact the Enrollment Coordinator at your local VA health care facility for assistance in scheduling an appointment.

Definitions of terms used on this form SERVICE-CONNECTED (SC): A veteran with 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 determination by VA that a service-connected disability is severe enough to warrant monetary compensation.

NONCOMPENSABLE: A determination by VA 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. Which sections of VA Form 10-10EZ should you complete?

Look at the table below to find out which sections of VA Form 10-10EZ you should complete. The shaded sections should be completed only if you answer "Yes" to Section VI agreeing to provide income and asset information to establish eligibility for care. You may agree to copayments without providing this detailed financial information.

Service-connected 50% to 100%. Answer YES in Section VI and complete Sections VII-IX to have your financial eligibility for waiver of travel deductions assessed .

I-IV X

Service-connected 30-40%. Answer YES in Section VI and complete Sections VII-IX to have your financial eligibility for cost-free medications for treatment of your nonservice-connected conditions and waiver of travel deductibles assessed.

X

Service-connected 0% (compensable) or service-connected 10-20%. Answer YES in Section VI and complete Sections VII-IX to have your financial eligibility for cost-free medications and beneficiary travel for treatment of your nonservice-connected conditions assessed.

X

A Former POW. Answer YES in Section VI and complete Sections VII-IX to have your financial eligibility for beneficiary travel assessed. Also, complete Section X if applying for long-term care.

X

VI

VII

VIII

IX

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

If you are...

X

X

X

Complete the sections marked with an X

X

XII X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

A veteran discharged from the military due to a disability incurred or aggravated in service or Purple Heart Medal recipient veteran. Answer YES in Section VI and complete Sections VII-IX to have your financial eligibility for cost-free medications and beneficiary travel assessed. Also, complete Section X if applying for long-term care.

Receiving nonservice-connected VA Pension, Aid and Attendance or Housebound benefits. Answer YES in Section VI and complete Sections VII-X to have your financial eligibility for long-term care assessed. Unmarried VA Pensioners are excluded from this requirement.

A recent combat veteran (e.g., OEF/OIF) with discharge from military within past 5 years or discharge from the military more than 5 years ago and applying for enrollment by Jan. 27, 2011. You are eligible for enrollment without providing your financial information. If you answer YES in Section VI and complete Sections VII-X you will have your priority for enrollment and financial eligibility for cost-free medical care, medications, long-term care and beneficiary travel for treatment of your nonservice- connected conditions assessed.

Service-connected 0% (noncompensable) or nonservice-connected with no special eligibilities listed above. Answer YES in Section VI and complete Sections VII-X to have your priority for enrollment and financial eligibility for cost-free medical care, medications, long-term care and beneficiary travel for treatment of your nonservice-connected conditions assessed.

X

X

X

X

X

X

X

VA FORM JUL 2008

10-10EZ

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

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