VA Form 10-10EZ — Application for Health Benefits

What is VA Form 10-10EZ?

VA Form 10-10EZ, Instructions and Enrollment Application for Health Benefits, is the application for VA health care. VA's page says you must be enrolled in VA health care to get care at VA health facilities, or to have VA cover care from an approved community care provider. The form also offers Registration, for veterans who qualify for particular care without enrolling, such as care for a service-connected disability or in the 12 months after a discharge for a line-of-duty disability.

All veterans complete Sections I to III: personal and contact details, next of kin and designee, military service and history (Purple Heart, POW, combat, Gulf War, service-connected rating), toxic exposures such as radiation, Gulf War locations, Agent Orange locations, burn pits and Camp Lejeune water, and other health insurance including Medicare and Medicaid. Sections IV to VIII cover your spouse and dependent child, employment and, if you choose to disclose it, last year's household income and deductible expenses, which VA uses for copay and priority decisions.

FileIt asks each item in plain English, prints your answers onto the VA's own PDF (FEB 2025 edition), repeats your name and SSN in the page headers, and files the finished application in your vault. You sign it in ink and mail it to the Health Eligibility Center. VA's page says you can also apply online instead. FileIt never submits anything to VA.

Who needs to fill out VA Form 10-10EZ?

• Veterans applying for VA health care for the first time.
• Recently separated service members and recent combat veterans.
• Veterans exposed to toxins during service, such as burn pits, Agent Orange, radiation or Camp Lejeune water, who want exposure-related care.
• Veterans with a service-connected rating who need registration for care for that condition.
• Family members or representatives with power of attorney completing the application for a veteran.

When to use VA Form 10-10EZ

• Before your first appointment at a VA facility or with a VA community care provider.
• After leaving the military, especially if you served in a combat theater or a listed exposure location.
• When your circumstances change and you want VA to reassess eligibility. If you are already enrolled, VA's page points to VA Form 10-10EZR for updates.

What you need before you start

• Your Social Security number, date and place of birth, and mailing and home addresses.
• Discharge or separation papers such as a DD-214 (optional, but VA says attaching a copy can speed up processing if you don't get VA benefits yet).
• Your last branch of service, entry and discharge dates, discharge type and service number.
• The approximate dates (MM/YYYY) you served in Gulf War or herbicide locations, or were exposed to hazards.
• Your health insurance, Medicare and Medicaid details: company, policy holder, policy number, group code and Medicare number.
• Your spouse's and dependent child's names, dates of birth, Social Security numbers and dates of marriage or dependency.
• If you disclose finances: last calendar year's gross income, net farm, ranch, property or business income, other income, and non-reimbursed medical, funeral and education expenses.

What’s on VA Form 10-10EZ

The 2025 edition has 6 pages. FileIt asks for it in 11 parts:

1. Section I: General informationVeteran
2. Section I: Next of kin, emergency contact and your VA facilityVeteran
3. Section II: Military service informationVeteran
4. Section II: Military exposure informationVeteran
5. Section III: Insurance informationVeteran
6. Section IV: SpouseVeteran
7. Section IV: Dependent childVeteran
8. Section IV: SupportVeteran
9. Section V: Employment informationVeteran
10. Sections VI to VIII: Financial disclosureVeteran
11. Consent, assignment of benefits and signatureVeteran

How to fill out VA Form 10-10EZ, step by step

1 Type of benefit

Choose Enrollment (the full VA medical benefits package) or Registration (VA health services for veterans who meet the "enrollment not required" criteria). Registration needs only Sections I, II and III.

2 Section I: General information

Your name (last, first, middle), preferred name, mother's maiden name, sex, race and ethnicity (for statistics only), SSN, date and place of birth, preferred language, religion, mailing and home addresses, phones and email, and marital status. Then next of kin, an emergency contact, a designee for any personal property left at VA, your preferred VA facility and whether VA should call to schedule your first appointment.

3 Section II: Military service

Last branch, entry and discharge dates, discharge type and service number, then yes or no for a Purple Heart, prisoner of war, combat after 11/11/1998, disability discharge, Gulf War service in SW Asia (August 2, 1990 to November 11, 1998) and a service-connected rating.

4 Section II: Military exposures

Answer yes or no for ionizing radiation locations, Gulf War hazard locations, deployments supporting operations such as Enduring Freedom and Iraqi Freedom, and herbicide locations, with approximate dates. Then tick any exposure: air pollutants, chemicals, Camp Lejeune water, radiation, SHAD, occupational hazards, asbestos, mustard gas, warfare agents or other.

5 Section III: Insurance

List every health insurer that covers you, including through a spouse, with the policy holder, policy number and group code. Say whether you are eligible for Medicaid and enrolled in Medicare Part A, with the effective date and Medicare number.

6 Section IV: Dependents

Your spouse (even if you didn't live together, as long as you contributed support last year) and a dependent child: names, SSNs, dates of birth, and for the child the relationship, any permanent disability before 18, school attendance between 18 and 23, and education expenses paid from the child's income.

7 Sections V to VIII: Employment and finances

Your employment status and employer. Then choose whether to disclose household finances. Only veterans without a service-connected condition and 0% service-connected veterans must, and many groups are exempt. If you do, give last year's income for you, your spouse and one child, and your deductible medical, funeral and education expenses.

8 Consent and signature

By submitting you agree to pay applicable VA copayments and to receive communications from VA. The assignment of benefits lets VA bill your health plan for non-service-connected care. Sign and date the form in ink.

Common mistakes to avoid

• Forgetting to sign and date the form. VA says it returns applications that aren't signed and dated appropriately.
• Signing with an X without two witnesses who sign and print their names.
• Leaving out insurance you have through a spouse or significant other.
• Reporting SSI, welfare or other need-based payments as income. The instructions list them among amounts not to report.
• Listing dependents' educational expenses as your own in Section VIII.
• Filling in 1C (future discharge date) for a discharge that has already happened. That belongs in 1D.

After you fill it out

Print the application, sign and date it in ink, attach any continuation sheets, supporting papers (such as your DD-214) and power of attorney documents, and mail it to the Health Eligibility Center, PO Box 5207, Janesville, WI 53547-5207.

Bring your insurance, Medicare and Medicaid cards to each health care appointment, as the instructions ask.

Keep the filed PDF and your discharge papers together in your vault. Once enrolled, VA's page points to VA Form 10-10EZR for updating your personal, insurance, financial or military information.

VA Form 10-10EZ: frequently asked questions

Official sources

• Blank form (PDF), published by U.S. Department of Veterans Affairs, Veterans Health Administration (VHA): https://www.va.gov/vaforms/medical/pdf/VA%20Form%2010-10EZ.pdf
• Official instructions and guidance: https://www.va.gov/find-forms/about-form-10-10ez/
• Edition shown on this page: VA Form 10-10EZ, FEB 2025 (OMB No. 2900-0091, expires 07/31/2027) (checked 2026-09-28).

FileIt is not affiliated with or endorsed by U.S. Department of Veterans Affairs, Veterans Health Administration (VHA) or any government. This page explains the form in general terms and is not legal, tax or immigration advice. Always read the official instructions, and check that you are using the edition the recipient accepts. Page last reviewed 2026-09-28.

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