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.
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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. If you stay on 10ea single page for more than 20 minutes, a window will be displayed asking if you want to continue or close the online form. You will be provided an opportunity to review and change your information prior to submission.
Typically, veterans who have NOT previously enrolled or applied for VA health care benefits should use this form.
To navigate this form, use the buttons provided on each page.
If you have delegated someone else to sign the form, we must receive a copy of the Power of Attorney. Click the “Continue” button promptly to avoid closing your form and erasing the information you have entered. 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.
I have read this page and want to go to the Online Submission Form.
If you do not see the words “Print test successful”you should check to make sure that Acrobat Reader has been installed. Click this link to run a Printing Test to ensure that you will be able to print your completed form. If a new window does not appear, please check for a pop-up blocker.
VA Form 10-10EZ – Application for Medical Benefits (Enroll)
10es Click here to obtain a free copy of the Adobe Acrobat Reader software. If your browser does not have scripting enabled, or it does not support it.
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.
You the 110ez must sign and date the printed copy and mail or fax it to the selected VA Facility. 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. Additionally, the online form limits the amount of time your browser can remain idle.
VA Form EZ – Application for Medical Benefits (Enroll) (Health Eligibility Center)
The witnesses must also sign the form and print their names. This will result in a delay in processing the application.
The forms may not function correctly. Because of the sensitive nature of the information requested, the information is not saved in your computer or on our web server.
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110ez, the form must be completed in a single session. 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.
Do not use the browser ” Back ” and ” Forward ” buttons. We will begin 10ea the application upon receipt of the signed form. Enter your search text Button to start search. 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.