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

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form 10-10EZR Health Benefits Update Form	Form and Instruction	New	Repair queued
Form 10-10EZR Updated VA Form 10-10EZR (2022)	Form and Instruction	New	Repair queued
Form 10-10EZ Application for Health Benefits	Form and Instruction	New	Available
Form 10-10EZ Updated VA Form 10-10EZ (2022)	Form and Instruction	New	Repair queued
Form 10-10HS VA Request for Hardship Determination	Form and Instruction	Unchanged	Available
Form 10-10HS VA Form 10-10HS -- Request for Hardship Determination	Form and Instruction	Unchanged	Repair queued
Form 10-10EZR Health Benefits Update Form	Form and Instruction	Removed	Repair queued
Form 10-10EZR VA Form 10-10EZR -- Health Benefits Update Form	Form and Instruction	Removed	Repair queued
Form 10-10EZ Application for Health Benefits	Form and Instruction	Removed	Available
Form 10-10EZ VA Form 10-10EZ -- Application for Health Benefits	Form and Instruction	Removed	Repair queued
2900-0091_Non-Substantive Change Memorandum_09272022.docx	Justification for No Material/Nonsubstantive Change	Uploaded 2022-09-29	Repair queued
10_10EZ_screencapture_2021.pdf	Supplementary Document	Uploaded 2021-06-15	Repair queued
30 day FRN_2900-0091_Health Benefits Application Renewal Hardship Determ_02122021.pdf	Supplementary Document	Uploaded 2021-02-17	Repair queued
60 day FRN_2900-0091_Health Benefits Application Renewal Hardship Determ_10282020.pdf	Supplementary Document	Uploaded 2020-11-28	Repair queued
2900-0091_VA Health Benefits Forms_Supp Stmnt A_revised Feb 2021.docx	Supporting Statement A	Uploaded 2022-09-30	Repair queued

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
256200	Updated VA Form 10-10EZR (2022)	Form and Instruction	New	Health Benefits Update Form
256200	Updated VA Form 10-10EZR (2022)	Form and Instruction	New
256198	Updated VA Form 10-10EZ (2022)	Form and Instruction	New	Application for Health Benefits
256198	Updated VA Form 10-10EZ (2022)	Form and Instruction	New
244175	VA Form 10-10HS -- Request for Hardship Determination	Form and Instruction	Unchanged	VA Request for Hardship Determination
244175	VA Form 10-10HS -- Request for Hardship Determination	Form and Instruction	Unchanged
237785	VA Form 10-10EZR -- Health Benefits Update Form	Form and Instruction	Removed	Health Benefits Update Form
237785	VA Form 10-10EZR -- Health Benefits Update Form	Form and Instruction	Removed
237784	VA Form 10-10EZ -- Application for Health Benefits	Form and Instruction	Removed	Application for Health Benefits
237784	VA Form 10-10EZ -- Application for Health Benefits	Form and Instruction	Removed

ICR Details

OMB Control No: 2900-0091	ICR Reference No: 202209-2900-014
Status: Historical Active	Previous ICR Reference No: 202010-2900-007
Agency/Subagency: VA	Agency Tracking No: 2900-0091
Title: VA Health Benefits: Application, Update, Hardship Determination - VA Forms 10-10EZ,10-10EZR and 10-10HS
Type of Information Collection: No material or nonsubstantive change to a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 10/04/2022
Retrieve Notice of Action (NOA)	Date Received in OIRA: 09/30/2022
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	06/30/2024	06/30/2024	06/30/2024
Responses	1,406,000	0	1,406,000
Time Burden (Hours)	615,350	0	615,350
Cost Burden (Dollars)	0	0	0

---

Abstract: 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.

---

Authorizing Statute(s): 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
  

Citations for New Statutory Requirements: PL: Pub.L. 115 - 182 101 Name of Law: MISSION Act of 2018

---

Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

---

Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	85 FR 68418	10/28/2020
30-day Notice:	Federal Register Citation:	Citation Date:
	86 FR 9425	02/12/2021
Did the Agency receive public comments on this ICR? No

---

Number of Information Collection (IC) in this ICR: 3

table that charts list of burden

IC Title	Form No.	Form Name
Updated VA Form 10-10EZ (2022)	10-10EZ	Application for Health Benefits
Updated VA Form 10-10EZR (2022)	10-10EZR	Health Benefits Update Form
VA Form 10-10EZ -- Application for Health Benefits	10-10EZ	Application for Health Benefits
VA Form 10-10EZR -- Health Benefits Update Form	10-10EZR	Health Benefits Update Form
VA Form 10-10HS -- Request for Hardship Determination	10-10HS	VA Request for Hardship Determination

---

ICR Summary of Burden

table that charts list of burden

	Total Approved	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	1,406,000	0	1,399,000	-1,399,000	0
Annual Time Burden (Hours)	615,350	615,350	0	613,600	-613,600	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

Burden increases because of Program Change due to Agency Discretion: Yes

Burden Increase Due to: Miscellaneous Actions

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement: Program Office made non-substantive updates to VA Forms 10-10EZ and 10-10EZR -- updated forms will be used going forward, but burden hours did not change.

---

Annual Cost to Federal Government: $5,531,450

Does this IC contain surveys, censuses, or employ statistical methods? No

Does this ICR request any personally identifiable information (see OMB Circular No. A-130 for an explanation of this term)? Please consult with your agency's privacy program when making this determination.     Yes

Does this ICR include a form that requires a Privacy Act Statement (see 5 U.S.C. §552a(e)(3))? Please consult with your agency's privacy program when making this determination.     Yes

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? No

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? No

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? No

Is this ICR related to the Pandemic Response? No

---

Common Form ICR:  No

---

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:

(a) It is necessary for the proper performance of agency functions;

(b) It avoids unnecessary duplication;

(c) It reduces burden on small entities;

(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;

(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;

(f) It indicates the retention periods for recordkeeping requirements;

(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:

(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;

(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.

(i) It uses effective and efficient statistical survey methodology (if applicable); and

(j) It makes appropriate use of information technology.

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.

Certification Date: 09/30/2022

---