VA Form 10-10EZ

Application for Health Benefits

HealthcareOfficial VA form on VA.gov

Who fills it

veteran

Journey phase

VA Healthcare

Estimated time

30-45 minutes.

When to file

As soon as possible after separation. Combat veterans have a 10-year enhanced eligibility window from their most recent combat discharge. Earlier enrollment = longer access history.

You want access to VA health care services for any reason - not just for service-connected conditions. Even if your conditions are not service-connected, you may qualify based on combat service, income, or other factors.

Gather before you start

—DD-214 (character of discharge)

—Social Security number

—Current insurance cards (Medicare, Medicaid, private)

—Annual income information (only needed if not in a higher priority group)

—Financial information for spouse and dependents if applicable

—List of current medications, allergies, and primary health conditions

—Primary care provider information if you have one

Attach with the form

—DD-214 (copy)

—Insurance cards / Medicare card if applicable

—Most recent federal tax return or income documentation if in a lower priority group

Section I - Veteran Identification

1 field

Blocks 1-8Name, SSN, DOB, gender, address, phone, emailPII

Your identifying information. VA uses SSN to match you with your service records and any existing VA records. Include a reliable email address - VA sends important notices and appointment reminders electronically.

Example

(legal name, SSN, current contact information)

Common mistakes

Using a PO Box when a physical address is needed for some VA mail.
Outdated phone number - appointment reminders go to the number on file.

Section II - Military Service

1 field · 2 citations

Blocks 9-16Branch, service dates, discharge type, combat service, POW/MIA

Service history determines your priority group for VA health care. Combat veterans (discharged after 11/11/1998 and served in combat operations) receive free care for 10 years for any condition related to their service. Veterans rated 50%+ SC receive Priority Group 1 (no copays for most services). Also note if you were a POW or served in areas with toxic exposures - this triggers the PACT Act screening.

Example

(military branch, dates, discharge character, combat service yes/no)

Common mistakes

Not noting combat service - this significantly affects your priority group and eliminates copays for 10 years.
Using the wrong discharge character - "General (Under Honorable Conditions)" is different from "Honorable" and affects some eligibility determinations.
Not noting Reserve/Guard activation periods that involved combat - these count for the combat veteran priority.

Authority

38 CFR 17.36 - PG 1–8 enrollment categories under 38 CFR 17.36.

38 USC 1710 - Core VA health care eligibility.

Section III - Insurance Information

1 field

Blocks 17-24Current health insurance (Medicare, Medicaid, private)

List all current health insurance. VA will bill other insurance for care related to non-service-connected conditions. This does NOT affect your eligibility or copay amounts for service-connected care. Having insurance may reduce your out-of-pocket costs for non-SC care.

Example

e.g., Medicare Part A and B; United Healthcare; No other insurance

Common mistakes

Thinking that having insurance makes you ineligible for VA care - it does not.
Not listing Medicare - VA can bill Medicare for certain services.
Not knowing that VA does NOT bill Medicare for SC-related care.

Section IV - Income Information (if applicable)

1 field

Blocks 25-35Previous year's gross household income and deductible expenses

If you are NOT in a high-priority group (combat veteran, SC 50%+, POW, Medal of Honor), VA may use income to determine copay amounts and enrollment priority. Report last year's gross income for yourself, spouse, and dependents. Also report unreimbursed medical expenses, educational expenses, and burial expenses which reduce countable income. Priority Group 8 (above income threshold) may not be eligible for enrollment depending on VA funding.

Example

(last year gross income; VA will verify against IRS)

Common mistakes

Thinking you earn too much to qualify - income thresholds vary by location (geographic means test); check current thresholds at VA.gov.
Not reporting unreimbursed medical expenses - they reduce countable income and can move you to a higher priority group.

Section V - Toxic Exposure Screening (PACT Act)

1 field · 1 citation

Blocks 36-40Service locations associated with toxic exposures

Under the PACT Act, VA must screen every enrolling veteran for toxic exposure. Disclose if you served in any location with potential toxic exposures: burn pits (Afghanistan, Iraq, other locations post-8/2/1990), Agent Orange (Vietnam, Korean DMZ, Thailand, certain other locations), contaminated water (Camp Lejeune), ionizing radiation, or other hazardous exposures. This triggers a free toxic-exposure clinical evaluation.

Example

e.g., Served at Bagram Airfield, Afghanistan (burn pits) 2008-2009; No other toxic exposures

Common mistakes

Skipping or minimizing this section - PACT Act screening is the entry point for burn-pit and toxic-exposure health monitoring.
Not knowing about Camp Lejeune water contamination eligibility - family members who lived on-base 1953-1987 may also qualify for VA care under CLFMP.

Authority

38 USC 1710 - Core VA health care eligibility.

Related ClaimRecon tools

Pact Checker - Verify PACT Act presumptive eligibility for your service locations.

Section VI - Certification

1 field

Blocks 41-42Veteran signature and datePII

Sign and date under penalty of perjury. Enrollment is active within approximately 1 week after VA processes the application. You can also enroll online at va.gov/health-care/apply/application/ or call 1-877-222-8387.

Example

(signature/date)

Common mistakes

Not following up after 2-3 weeks - if you don't receive confirmation, call VA enrollment.
Not knowing about the online enrollment option - va.gov enrollment is often faster than paper.

Statutory & regulatory authority

38 CFR 17.36 - PG 1–8 enrollment categories under 38 CFR 17.36.

38 USC 1710 - Core VA health care eligibility.

VA Form 10-10EZ

Application for Health Benefits

HealthcareOfficial VA form on VA.gov

Who fills it

veteran

Journey phase

VA Healthcare

Estimated time

30-45 minutes.

When to file

As soon as possible after separation. Combat veterans have a 10-year enhanced eligibility window from their most recent combat discharge. Earlier enrollment = longer access history.

Gather before you start

—DD-214 (character of discharge)

—Social Security number

—Current insurance cards (Medicare, Medicaid, private)

—Annual income information (only needed if not in a higher priority group)

—Financial information for spouse and dependents if applicable

—List of current medications, allergies, and primary health conditions

—Primary care provider information if you have one

Attach with the form

—DD-214 (copy)

—Insurance cards / Medicare card if applicable

—Most recent federal tax return or income documentation if in a lower priority group

Section I - Veteran Identification

1 field

Blocks 1-8Name, SSN, DOB, gender, address, phone, emailPII

Example

(legal name, SSN, current contact information)

Common mistakes

Using a PO Box when a physical address is needed for some VA mail.
Outdated phone number - appointment reminders go to the number on file.

Section II - Military Service

1 field · 2 citations

Blocks 9-16Branch, service dates, discharge type, combat service, POW/MIA

Example

(military branch, dates, discharge character, combat service yes/no)

Common mistakes

Not noting combat service - this significantly affects your priority group and eliminates copays for 10 years.
Using the wrong discharge character - "General (Under Honorable Conditions)" is different from "Honorable" and affects some eligibility determinations.
Not noting Reserve/Guard activation periods that involved combat - these count for the combat veteran priority.

Authority

38 CFR 17.36 - PG 1–8 enrollment categories under 38 CFR 17.36.

38 USC 1710 - Core VA health care eligibility.

Section III - Insurance Information

1 field

Blocks 17-24Current health insurance (Medicare, Medicaid, private)

Example

e.g., Medicare Part A and B; United Healthcare; No other insurance

Common mistakes

Thinking that having insurance makes you ineligible for VA care - it does not.
Not listing Medicare - VA can bill Medicare for certain services.
Not knowing that VA does NOT bill Medicare for SC-related care.

Section IV - Income Information (if applicable)

1 field

Blocks 25-35Previous year's gross household income and deductible expenses

Example

(last year gross income; VA will verify against IRS)

Common mistakes

Thinking you earn too much to qualify - income thresholds vary by location (geographic means test); check current thresholds at VA.gov.
Not reporting unreimbursed medical expenses - they reduce countable income and can move you to a higher priority group.

Section V - Toxic Exposure Screening (PACT Act)

1 field · 1 citation

Blocks 36-40Service locations associated with toxic exposures

Example

e.g., Served at Bagram Airfield, Afghanistan (burn pits) 2008-2009; No other toxic exposures

Common mistakes

Skipping or minimizing this section - PACT Act screening is the entry point for burn-pit and toxic-exposure health monitoring.
Not knowing about Camp Lejeune water contamination eligibility - family members who lived on-base 1953-1987 may also qualify for VA care under CLFMP.

Authority

38 USC 1710 - Core VA health care eligibility.

Related ClaimRecon tools

Pact Checker - Verify PACT Act presumptive eligibility for your service locations.

Section VI - Certification

1 field

Blocks 41-42Veteran signature and datePII

Example

(signature/date)

Common mistakes

Not following up after 2-3 weeks - if you don't receive confirmation, call VA enrollment.
Not knowing about the online enrollment option - va.gov enrollment is often faster than paper.

Statutory & regulatory authority

38 CFR 17.36 - PG 1–8 enrollment categories under 38 CFR 17.36.

38 USC 1710 - Core VA health care eligibility.

VA Form 10-10EZ

Application for Health Benefits

HealthcareOfficial VA form on VA.gov

Who fills it

veteran

Journey phase

VA Healthcare

Estimated time

30-45 minutes.

When to file

As soon as possible after separation. Combat veterans have a 10-year enhanced eligibility window from their most recent combat discharge. Earlier enrollment = longer access history.

Gather before you start

—DD-214 (character of discharge)

—Social Security number

—Current insurance cards (Medicare, Medicaid, private)

—Annual income information (only needed if not in a higher priority group)

—Financial information for spouse and dependents if applicable

—List of current medications, allergies, and primary health conditions

—Primary care provider information if you have one

Attach with the form

—DD-214 (copy)

—Insurance cards / Medicare card if applicable

—Most recent federal tax return or income documentation if in a lower priority group

Section I - Veteran Identification

1 field

Blocks 1-8Name, SSN, DOB, gender, address, phone, emailPII

Example

(legal name, SSN, current contact information)

Common mistakes

Using a PO Box when a physical address is needed for some VA mail.
Outdated phone number - appointment reminders go to the number on file.

Section II - Military Service

1 field · 2 citations

Blocks 9-16Branch, service dates, discharge type, combat service, POW/MIA

Example

(military branch, dates, discharge character, combat service yes/no)

Common mistakes

Not noting combat service - this significantly affects your priority group and eliminates copays for 10 years.
Using the wrong discharge character - "General (Under Honorable Conditions)" is different from "Honorable" and affects some eligibility determinations.
Not noting Reserve/Guard activation periods that involved combat - these count for the combat veteran priority.

Authority

38 CFR 17.36 - PG 1–8 enrollment categories under 38 CFR 17.36.

38 USC 1710 - Core VA health care eligibility.

Section III - Insurance Information

1 field

Blocks 17-24Current health insurance (Medicare, Medicaid, private)

Example

e.g., Medicare Part A and B; United Healthcare; No other insurance

Common mistakes

Thinking that having insurance makes you ineligible for VA care - it does not.
Not listing Medicare - VA can bill Medicare for certain services.
Not knowing that VA does NOT bill Medicare for SC-related care.

Section IV - Income Information (if applicable)

1 field

Blocks 25-35Previous year's gross household income and deductible expenses

Example

(last year gross income; VA will verify against IRS)

Common mistakes

Thinking you earn too much to qualify - income thresholds vary by location (geographic means test); check current thresholds at VA.gov.
Not reporting unreimbursed medical expenses - they reduce countable income and can move you to a higher priority group.

Section V - Toxic Exposure Screening (PACT Act)

1 field · 1 citation

Blocks 36-40Service locations associated with toxic exposures

Example

e.g., Served at Bagram Airfield, Afghanistan (burn pits) 2008-2009; No other toxic exposures

Common mistakes

Skipping or minimizing this section - PACT Act screening is the entry point for burn-pit and toxic-exposure health monitoring.
Not knowing about Camp Lejeune water contamination eligibility - family members who lived on-base 1953-1987 may also qualify for VA care under CLFMP.

Authority

38 USC 1710 - Core VA health care eligibility.

Related ClaimRecon tools

Pact Checker - Verify PACT Act presumptive eligibility for your service locations.

Section VI - Certification

1 field

Blocks 41-42Veteran signature and datePII

Example

(signature/date)

Common mistakes

Not following up after 2-3 weeks - if you don't receive confirmation, call VA enrollment.
Not knowing about the online enrollment option - va.gov enrollment is often faster than paper.

Statutory & regulatory authority

38 CFR 17.36 - PG 1–8 enrollment categories under 38 CFR 17.36.

38 USC 1710 - Core VA health care eligibility.

VA Form 10-10EZ

Application for Health Benefits

HealthcareOfficial VA form on VA.gov

Who fills it

veteran

Journey phase

VA Healthcare

Estimated time

30-45 minutes.

When to file

As soon as possible after separation. Combat veterans have a 10-year enhanced eligibility window from their most recent combat discharge. Earlier enrollment = longer access history.

Gather before you start

—DD-214 (character of discharge)

—Social Security number

—Current insurance cards (Medicare, Medicaid, private)

—Annual income information (only needed if not in a higher priority group)

—Financial information for spouse and dependents if applicable

—List of current medications, allergies, and primary health conditions

—Primary care provider information if you have one

Attach with the form

—DD-214 (copy)

—Insurance cards / Medicare card if applicable

—Most recent federal tax return or income documentation if in a lower priority group

Section I - Veteran Identification

1 field

Blocks 1-8Name, SSN, DOB, gender, address, phone, emailPII

Example

(legal name, SSN, current contact information)

Common mistakes

Using a PO Box when a physical address is needed for some VA mail.
Outdated phone number - appointment reminders go to the number on file.

Section II - Military Service

1 field · 2 citations

Blocks 9-16Branch, service dates, discharge type, combat service, POW/MIA

Example

(military branch, dates, discharge character, combat service yes/no)

Common mistakes

Not noting combat service - this significantly affects your priority group and eliminates copays for 10 years.
Using the wrong discharge character - "General (Under Honorable Conditions)" is different from "Honorable" and affects some eligibility determinations.
Not noting Reserve/Guard activation periods that involved combat - these count for the combat veteran priority.

Authority

38 CFR 17.36 - PG 1–8 enrollment categories under 38 CFR 17.36.

38 USC 1710 - Core VA health care eligibility.

Section III - Insurance Information

1 field

Blocks 17-24Current health insurance (Medicare, Medicaid, private)

Example

e.g., Medicare Part A and B; United Healthcare; No other insurance

Common mistakes

Thinking that having insurance makes you ineligible for VA care - it does not.
Not listing Medicare - VA can bill Medicare for certain services.
Not knowing that VA does NOT bill Medicare for SC-related care.

Section IV - Income Information (if applicable)

1 field

Blocks 25-35Previous year's gross household income and deductible expenses

Example

(last year gross income; VA will verify against IRS)

Common mistakes

Thinking you earn too much to qualify - income thresholds vary by location (geographic means test); check current thresholds at VA.gov.
Not reporting unreimbursed medical expenses - they reduce countable income and can move you to a higher priority group.

Section V - Toxic Exposure Screening (PACT Act)

1 field · 1 citation

Blocks 36-40Service locations associated with toxic exposures

Example

e.g., Served at Bagram Airfield, Afghanistan (burn pits) 2008-2009; No other toxic exposures

Common mistakes

Skipping or minimizing this section - PACT Act screening is the entry point for burn-pit and toxic-exposure health monitoring.
Not knowing about Camp Lejeune water contamination eligibility - family members who lived on-base 1953-1987 may also qualify for VA care under CLFMP.

Authority

38 USC 1710 - Core VA health care eligibility.

Related ClaimRecon tools

Pact Checker - Verify PACT Act presumptive eligibility for your service locations.

Section VI - Certification

1 field

Blocks 41-42Veteran signature and datePII

Example

(signature/date)

Common mistakes

Not following up after 2-3 weeks - if you don't receive confirmation, call VA enrollment.
Not knowing about the online enrollment option - va.gov enrollment is often faster than paper.

Statutory & regulatory authority

38 CFR 17.36 - PG 1–8 enrollment categories under 38 CFR 17.36.

38 USC 1710 - Core VA health care eligibility.