Information Collection

VA Form 10-10EZR

IC 256200 under ICR 202402-2900-001 · OMB 2900-0091.

⚠️ Notice: This information collection may be referencing outdated material.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

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 10-10EZR VA Form 10-10EZR	Form and Instruction
10-10EZR Health Benefits Update Form VA Form 10-10EZR.pdf	Form and Instruction
10-10EZR Health Benefits Update Form VA Form 10-10EZR.pdf	Form and Instruction
10-10EZR Health Benefits Update Form VA Form 10-10EZR_PACT Act - Section 103_updates_Jan 2024.pdf	Form and Instruction
10-10EZR Health Benefits Update Form VA Form 10-10EZR_PACT Act - Section 103_updates_Jan 2024.pdf	Form and Instruction

IC Title:

VA Form 10-10EZR

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:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	10-10EZR	Health Benefits Update Form	VA Form 10-10EZR.pdf		Yes	Yes	Fillable Fileable
Form and Instruction	10-10EZR	Health Benefits Update Form	VA Form 10-10EZR_PACT Act - Section 103_updates_Jan 2024.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: 859,000

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 25 %

table that charts list of burden
	Requested	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	859,000	0	859,000
Annual IC Time Burden (Hours)	386,550	42,950	343,600
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

table that charts IC Documents
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.