X hits on this document

PDF document

Step 1: Before You Start . . . What is VA Form 10-10EZ used for? - page 3 / 5

11 views

0 shares

0 downloads

0 comments

3 / 5

OMB Approved No. 2900-0091 Estimated Burden Avg. 45 min.

APPLICATION FOR HEALTH BENEFITS

SECTION I - GENERAL INFORMATION

Federal law provides criminal penalties, including a fine and/or imprisonment for up to 5 years, for concealing a material fact or making a materially false statement. (See 18 U.S.C. 1001)

1. VETERAN'S NAME (Last, First, Middle Name)

2. OTHER NAMES USED

3. MOTHER'S MAIDEN NAME

4. GENDER

MALE

FEMALE

5. ARE YOU SPANISH, HISPANIC, OR LATINO?

6. WHAT IS YOUR RACE? (You may check more than one.) (Information is required for statistical purposes only.)

YES

NO

AMERICAN INDIAN OR ALASKA NATIVE

BLACK OR AFRICAN AMERICAN

ASIAN

WHITE

NATIVE HAWAIIAN OR OTHER PACIFIC ISLANDER

7. SOCIAL SECURITY NUMBER

9. DATE OF BIRTH (mm/dd/yyyy)

8. CLAIM NUMBER

9A. PLACE OF BIRTH (City and State)

10. RELIGION

11. PERMANENT ADDRESS (Street)

11A. CITY

11B. STATE

11C. ZIP CODE (9 digits)

11D. COUNTY

11E. HOME TELEPHONE NUMBER (Include area code)

11F. E-MAIL ADDRESS

11G. CELLULAR TELEPHONE NUMBER (Include area code)

11H. PAGER NUMBER (Include area code)

12. TYPE OF BENEFIT(S) APPLIED FOR (You may check more than one)

HEALTH SERVICES

NURSING HOME

DOMICILIARY

DENTAL

13. IF APPLYING FOR HEALTH SERVICES OR ENROLLMENT, WHICH VA MEDICAL CENTER OR OUTPATIENT CLINIC DO YOU PREFER?

14. DO YOU WANT AN APPOINTMENT WITH A VA DOCTOR OR PROVIDER AS SOON AS ONE BECOMES AVAILABLE?

15. HAVE YOU BEEN SEEN AT A VA HEALTH CARE FACILITY?

YES

NO

I am only enrolling in case I need care in the future.

YES, LOCATION:

NO

16. CURRENT MARITAL STATUS (Check one)

MARRIED

NEVER MARRIED

SEPARATED

WIDOWED

DIVORCED

UNKNOWN

17. NAME, ADDRESS AND RELATIONSHIP OF NEXT OF KIN

17A. NEXT OF KIN'S HOME TELEPHONE NUMBER (Include area code)

17B. NEXT OF KIN'S WORK TELEPHONE NUMBER (Include area code)

18. NAME, ADDRESS AND RELATIONSHIP OF EMERGENCY CONTACT

18A. EMERGENCY CONTACT'S HOME TELEPHONE NUMBER (Include area code)

18B. EMERGENCY CONTACT'S WORK TELEPHONE NUMBER (Include area code)

19. INDIVIDUAL TO RECEIVE POSSESSION OF YOUR PERSONAL PROPERTY LEFT ON PREMISES UNDER VA CONTROL AFTER YOUR DEPARTURE OR AT THE TIME OF DEATH. NOTE:

THIS DOES NOT CONSTITUTE A WILL OR TRANSFER OF TITLE

(Check one)

EMERGENCY CONTACT

NEXT OF KIN

VA FORM JUL 2008

10-10EZ

PREVIOUS EDITIONS OF THIS FORM ARE NOT TO BE USED

PAGE 1

Document info
Document views11
Page views11
Page last viewedMon Dec 05 19:08:06 UTC 2016
Pages5
Paragraphs331
Words3960

Comments