X hits on this document

PDF document

Step 1: Before You Start . . . What is VA Form 10-10EZ used for? - page 4 / 5

12 views

0 shares

0 downloads

0 comments

4 / 5

APPLICATION FOR HEALTH BENEFITS, Continued

VETERAN'S NAME (Last, First, Middle)

SOCIAL SECURITY NUMBER

SECTION II - INSURANCE INFORMATION (Use a separate sheet for additional information) 1. ARE YOU COVERED BY HEALTH INSURANCE? (Including coverage 2. HEALTH INSURANCE COMPANY NAME, ADDRESS AND TELEPHONE NUMBER

through a spouse or another person)

YES

NO

3. NAME OF POLICY HOLDER

4. POLICY NUMBER

5. GROUP CODE

YES

NO

6. ARE YOU ELIGIBLE FOR MEDICAID?

  • 7.

    ARE YOU ENROLLED IN MEDICARE HOSPITAL INSURANCE PART A?

  • 8.

    ARE YOU ENROLLED IN MEDICARE HOSPITAL INSURANCE PART B?

7A. EFFECTIVE DATE

(mm/dd/yyyy)

8A. EFFECTIVE DATE

(mm/dd/yyyy)

9. NAME EXACTLY AS IT APPEARS ON YOUR MEDICARE CARD

10. MEDICARE CLAIM NUMBER

11. IS NEED FOR CARE DUE TO ON THE JOB INJURY? (Check one)

YES

NO

12. IS NEED FOR CARE DUE TO ACCIDENT? (Check One)

YES

NO

SECTION III - EMPLOYMENT INFORMATION

1. VETERAN'S EMPLOYMENT STATUS (Check one)

FULL TIME

NOT EMPLOYED

1A. COMPANY NAME, ADDRESS AND TELEPHONE NUMBER

If employed or retired, complete item 1A

2. SPOUSE'S EMPLOYMENT STATUS (Check one)

RETIRED

Date of retirement

NOT EMPLOYED

(mm/dd/yyyy)

PART TIME

FULL TIME

2A. COMPANY NAME, ADDRESS AND TELEPHONE NUMBER

If employed or retired, complete item 2A

PART TIME

RETIRED

Date of retirement (mm/dd/yyyy)

SECTION IV - MILITARY SERVICE INFORMATION

1. LAST BRANCH OF SERVICE

1A. LAST ENTRY DATE

1B. LAST DISCHARGE DATE

1C. DISCHARGE TYPE

1D. MILITARY SERVICE NUMBER

  • 2.

    CHECK YES OR NO

    • A.

      ARE YOU A PURPLE HEART AWARD RECIPIENT?

  • B.

    ARE YOU A FORMER PRISONER OF WAR?

  • C.

    DO YOU HAVE A VA SERVICE-CONNECTED RATING?

C1. IF YES, WHAT IS YOUR RATED PERCENTAGE?

D. DID YOU SERVE IN COMBAT AFTER 11/11/1998?

%

E. WAS YOUR DISCHARGE FROM MILITARY FOR A DISABILITY INCURRED OR AGGRAVATED IN THE LINE OF DUTY?

YES

NO

E1. ARE YOU RECEIVING DISABILITY RETIREMENT PAY INSTEAD OF VA COMPENSATION?

F. DO YOU NEED CARE OF CONDITIONS POTENTIALLY RELATED TO SERVICE IN SW ASIA DURING THE GULF WAR?

G. WERE YOU EXPOSED TO AGENT ORANGE WHILE SERVING IN VIETNAM?

  • H.

    WERE YOU EXPOSED TO RADIATION WHILE IN THE MILITARY?

  • I.

    DID YOU RECEIVE NOSE AND THROAT RADIUM TREATMENTS

WHILE IN THE MILITARY?

J. DO YOU HAVE A SPINAL CORD INJURY?

YES

NO

SECTION V - PAPERWORK REDUCTION ACT AND PRIVACY ACT INFORMATION

The Paperwork Reduction Act of 1995 requires us to notify you that this information collection is in accordance with the clearance requirements of Section 3507 of the Paperwork Reduction Act of 1995. We may not conduct or sponsor, and you are not required to respond to, a collection of information unless it displays a valid OMB number. We anticipate that the time expended by all individuals who must complete this form will average 45 minutes. This includes the time it will take to read instructions, gather the necessary facts and fill out the form.

Privacy Act Information: VA is asking you to provide the information on this form under 38 U.S.C. Sections 1705, 1710, 1712, and 1722 in order for VA to determine your eligibility for medical benefits. Information you supply may be verified through a computer-matching program. VA may disclose the information that you put on the form as permitted by law. VA may make a "routine use" disclosure of the information as outlined in the Privacy Act systems of records notices and in accordance with the VHA Notice of Privacy Practices. Providing the requested information is voluntary, but if any or all of the requested information is not provided, it may delay or result in denial of your request for health care benefits. Failure to furnish the information will not have any effect on any other benefits to which you may be entitled. If you provide VA your Social Security Number, VA will use it to administer your VA benefits. VA may also use this information to identify veterans and persons claiming or receiving VA benefits and their records, and for other purposes authorized or required by law.

VA FORM JUL 2008

10-10EZ

PAGE 2

Document info
Document views12
Page views12
Page last viewedTue Dec 06 08:19:08 UTC 2016
Pages5
Paragraphs331
Words3960

Comments