Information Collection

Application and Renewal for Health Benefits

IC 28251 under ICR 201306-2900-006 · 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⚠️ Notice: This information collection may be referencing outdated material.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 VA form 10-10EZ Application and Renewal for Health Benefits	Form
VA form 10-10EZ Application for Health Benefits VHA-1010EZ-new-fill V2v1_07302013.pdf www.va.gov/healtheligibility/application/	Form
VA Form 10-10HS Request for Hardship Determination 10-10HS-fill.pdf www.va.gov/vaforms/medical/pdf/vha-10-10HS.pdf	Form and Instruction
VA Form 10-10EZR Health Benefits Renewal Form VHA-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: 38 CFR 70.20 38 CFR 70.31(c) 38 CFR 70.31(e)

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	VA form 10-10EZ	Application for Health Benefits	VHA-1010EZ-new-fill V2v1_07302013.pdf	http://www.va.gov/healtheligibility/application/	Yes	Yes	Fillable Fileable
Form and Instruction	VA Form 10-10HS	Request for Hardship Determination	10-10HS-fill.pdf	http://www.va.gov/vaforms/medical/pdf/vha-10-10HS.pdf	Yes	No	Fillable Printable
Form	VA Form 10-10EZR	Health Benefits Renewal Form	VHA-10-10EZR-fill.pdf	http://www.va.gov/vaforms	Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title: 24VA19 Patient Medical Record - VA

FR Citation: 72 FR 15

Number of Respondents: 1,017,000

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	Previously Approved
Annual Number of Responses for this IC	1,017,000	-1,058,312	2,075,312
Annual IC Time Burden (Hours)	455,750	-658,990	1,114,740
Annual IC Cost Burden (Dollars)	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.