VA Health Benefits: Application, Update, Hardship Determination - VA Forms 10-10EZ,10-10EZR and 10-10HS

ICR 202010-2900-007

OMB: 2900-0091

Federal Form Document

ICR Details
2900-0091 202010-2900-007
Received in OIRA 201909-2900-005
VA 2900-0091
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 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

Not associated with rulemaking

  85 FR 68418 10/28/2020
86 FR 9425 02/12/2021

  Total Request Previously Approved Change Due to New Statute Change Due to Agency Discretion Change Due to Adjustment in Estimate Change Due to Potential Violation of the PRA
Annual Number of Responses 1,406,000 0 0 396,000 0 1,010,000
Annual Time Burden (Hours) 615,350 0 0 161,350 0 454,000
Annual Cost Burden (Dollars) 0 0 0 0 0 0
Miscellaneous Actions
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.

Frances O'Donnell 703 405-2449 [email protected]


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.

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