VA Health Benefits:
Application, Update, Hardship Determination - VA Forms
10-10EZ,10-10EZR and 10-10HS
Reinstatement with change of a previously approved collection
No
Regular
02/17/2021
Requested
Previously Approved
36 Months From Approved
1,406,000
0
615,350
0
0
0
Title 38 U.S.C. Chapter 17 authorizes
VA to provide hospital care, medical services, domiciliary care,
and nursing home care to eligible Veterans. Title 38 U.S.C. § 1705
requires VA to design, establish, and operate a system of annual
patient enrollment in accordance with a series of stipulated
priorities. Title 38 U.S.C. § 1722 establishes eligibility
assessment procedures for cost-free VA medical care, based on
income levels, which determines whether nonservice-connected and 0%
service-connected non-compensable Veterans are able to defray the
necessary expenses of care for nonservice-connected conditions.
Further, when the Veteran projects that his or her attributable
income for the current calendar year would be substantially below
the applicable income thresholds, the Veteran would be considered
unable to defray the expenses of care and VA may exempt the Veteran
from the requirement to pay copayments for hospital or outpatient
care. This collection of information is required to properly
administer health benefits to eligible Veterans: a. VA Form
10-10EZ, Application for Health Benefits, is used to collect
Veteran information during the initial application process for VA
medical care, nursing home, domiciliary, dental benefits, etc. b.
VA Form 10-10EZR, Health Benefits Update Form, is used to update a
Veteran’s personal information, such as marital status, address,
health insurance and financial information, for renewal of health
benefits. c. VA Form 10-10HS, Request for Hardship Determination,
is used to collect information from Veterans who are in a copay
required status for hospital care and medical services, but due to
a loss of income project their income for the current year will be
substantially below the VA means test limits. These forms collect
information to enroll a Veteran for health benefits, establish
basic eligibility, identify 3rd party health insurance coverage,
identify prescription copayment, provide for income verification,
and serve as a mechanism to make changes upon admission for
benefits or yearly financial updates.
US Code:
38 USC Chapter 17 Name of Law: HOSPITAL, NURSING HOME,
DOMICILIARY,
US Code:
38 USC 111(c)(1) Name of Law: Payments or allowances for
beneficiary travel
PL: Pub.L. 115 - 182 101 Name of Law: MISSION
Act of 2018
The burden increase is due to
an anticipated increase in annual Veteran applications for health
benefits, as well as an estimated increase in Veteran renewals and
updates to their enrollment for health benefits.
On behalf of this Federal agency, I certify that
the collection of information encompassed by this request complies
with 5 CFR 1320.9 and the related provisions of 5 CFR
1320.8(b)(3).
The following is a summary of the topics, regarding
the proposed collection of information, that the certification
covers:
(i) Why the information is being collected;
(ii) Use of information;
(iii) Burden estimate;
(iv) Nature of response (voluntary, required for a
benefit, or mandatory);
(v) Nature and extent of confidentiality; and
(vi) Need to display currently valid OMB control
number;
If you are unable to certify compliance with any of
these provisions, identify the item by leaving the box unchecked
and explain the reason in the Supporting Statement.