Information Collection

Application and Renewal for Health Benefits

IC 28251 under ICR 200703-2900-020 · OMB 2900-0091.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 2900-0091 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 10-10EZ Application and Renewal for Health Benefits	Form
10-10EZ Application for Health Care Benefits 2900-0091 VA Form 10-10ez.pdf www.va.gov/healtheligibility/application/	Form
10-10EZR HEALTH BENEFITS RENEWAL FORM 2900-0091 VA Form 10-10ezr-fill.pdf www.va.gov/vaforms	Form

IC Title:

Application and Renewal for Health Benefits

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation:

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	10-10EZ	Application for Health Care Benefits	2900-0091 VA Form 10-10ez.pdf	http://www.va.gov/healtheligibility/application/	Yes	Yes	Fillable Fileable
Form	10-10EZR	HEALTH BENEFITS RENEWAL FORM	2900-0091 VA Form 10-10ezr-fill.pdf	http://www.va.gov/vaforms	Yes	No	Fillable Printable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 1,904,940

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 3 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	1,904,940	4,940	0	1,900,000
Annual IC Time Burden (Hours)	1,008,180	0	3,180	1,005,000
Annual IC Cost Burden (Dollars)	0	0	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
No associated records found

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.