Applications and Renewal for Health Benefits

Application and Renewal for Health Benefits

⚠️ Notice: This information collection may be referencing outdated material.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

Documents and Forms

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

Information Collection (IC) Details

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:

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 AFILIACIÓN A LOS BENEFICIOS MÉDICOS	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 %

	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

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.