Information Collection

Applications and Renewal for Health Benefits

IC 212005 under ICR 201807-2900-003 · 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⚠️ Notice: This information collection may be referencing outdated material.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 Applications and Renewal for Health Benefits	Form and Instruction
10-10EZ Enrollment Application for Health Benefits 10-10EZ_August 2017.pdf	Form and Instruction
10-10EZR Health Benefits Update Form 10-10EZR_August 2017.pdf	Form and Instruction
10-10EZ - Spanish INSTRUCCIONES PARA SOLICITAR LA AFILIACIÓN A LOS BENEFIC 10-10EZ_Spanish.pdf	Form and Instruction

IC Title:

Applications 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 70.31(e) 38 CFR 70.20 38 CFR 70.31(c)

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 and Instruction	10-10EZ	Enrollment Application for Health Benefits	10-10EZ_August 2017.pdf		Yes	Yes	Fillable Fileable
Form and Instruction	10-10EZR	Health Benefits Update Form	10-10EZR_August 2017.pdf		Yes	Yes	Fillable Fileable
Form and Instruction	10-10EZ - Spanish Version	INSTRUCCIONES PARA SOLICITAR LA AFILIACIÃN A LOS BENEFICIOS MÃDICOS	10-10EZ_Spanish.pdf	TBD	Yes	Yes	Fillable Printable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title: 24VA19 Patient Medical Record - VA

FR Citation: 78 FR 17778

Number of Respondents: 1,010,000

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Previously Approved
Annual Number of Responses for this IC	1,010,000	1,010,000
Annual IC Time Burden (Hours)	454,000	454,000
Annual IC Cost Burden (Dollars)	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.