10 10EZ PDF

Fill out an Application for Health Benefits (VA Form EZ). Download VA Form EZ. You or someone acting as your power of attorney. Which sections of VA Form EZ should you complete? Definitions of terms used on this form. If you desire a health care appointment, contact the Enrollment . Complete and submit the VA Form EZ to apply for enrollment in the VA health care system.

Author: Mesida Akigor
Country: Kosovo
Language: English (Spanish)
Genre: Video
Published (Last): 3 May 2013
Pages: 212
PDF File Size: 13.78 Mb
ePub File Size: 4.99 Mb
ISBN: 368-8-51593-315-2
Downloads: 86251
Price: Free* [*Free Regsitration Required]
Uploader: Tojashicage

Click this link to run a Printing Test to ensure that you will be able to print your completed form. Additionally, the online form limits the amount of time your browser can remain idle.

I have read this page and want to go to the Online Submission Form. If a new window does not appear, please check for a pop-up blocker. Click here to obtain a free copy of the Adobe Acrobat Reader software.

VA Form EZ – Application for Medical Benefits (Enroll) (Health Eligibility Center)

If you stay on a single page for more than 20 minutes, a window will be displayed asking if you want to continue or close the online form. If you the applicant are unable to sign the form, two people known to the applicant may witness the applicant making an “X” on the form.


You the applicant must sign and date the printed copy and mail or fax it to the selected VA Facility. This is a “smart” form in that it will route you around sections of the form you do not have to complete which is based on the information you enter. 110 of the sensitive nature of the information requested, the information is not saved 100ez your computer or on our web server. If you do not see the words “Print test successful”you should check to make sure that Acrobat Reader has been installed.

The witnesses must also sign the form and print their names. You will be provided an opportunity to review and change your information prior to submission. 01ez

To navigate this form, use the buttons provided on each page. We will begin processing the application upon receipt of the signed form. Do not use the browser ” Back ” and 110 Forward ” buttons.

Posts Tagged ‘10-10EZ’

If the form is not signed and dated, VA will return it to the applicant to complete. You must have the latest version of Adobe Acrobat Reader on your computer to save or print the forms. Before beginning the online submission process, we suggest viewing or printing the EZ to assist 10wz in gathering all the information required to complete it. Therefore, the form must be completed in a single session.


Click the “Continue” button promptly to avoid closing your form and erasing the information you have entered. Typically, veterans who have NOT previously enrolled or applied for VA health care benefits should use this form.

This will result in a delay in processing the application. Instructions for Completing VA Form EZ On-Line Before beginning the online submission process, we suggest viewing or printing the EZ to assist you in gathering all the information required to complete it.


VA Form 10-10EZ – Application for Medical Benefits (Enroll)

If your browser does not have scripting enabled, or it does not support it. If you have a pop-up blocker on your computer, you should adjust it to allow a pop-up from this site or disable it while completing this form.

If you have delegated someone else to sign the form, we must receive a copy of the Power of Attorney. The forms may not function correctly. Enter your search text Button to start search.

work_outlinePosted in Love