VA Form 10-10EZ -- Application for Health Benefits

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

⚠️ Notice: This information collection may be referencing outdated material.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 VA Form 10-10EZ -- Application for Health Benefits Form and Instruction
10-10EZ Application for Health Benefits VA Form 10-10EZ_revised_Feb 2021.pdf Form and Instruction
10-10EZ Application for Health Benefits VA Form 10-10EZ_revised_Feb 2021.pdf Form and Instruction

Information Collection (IC) Details

IC Title:	VA Form 10-10EZ -- Application for Health Benefits	Agency IC Tracking Number:	2900-0091

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 38 CFR 58.12

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	Application for Health Benefits	VA Form 10-10EZ_revised_Feb 2021.pdf		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: 78 FR 17778

Number of Respondents: 540,000	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 25 %

	Approved	Program Change Due to Agency Discretion	Change Due to Potential Violation of the PRA
Annual Number of Responses for this IC	540,000	40,000	500,000
Annual IC Time Burden (Hours)	270,000	20,000	250,000
Annual IC Cost Burden (Dollars)	0	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.