Information Collection

VA Form 10-10EZR

IC 256200 under ICR 202504-2900-005 · 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⚠️ Notice: This information collection may be referencing outdated material.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

Document Name Document Type
Form 10-10EZR Health Benefits Update Form VA Form 10-10EZR Form and Instruction
10-10EZR Health Benefits Update Form VA Form 10-10EZR_EO revision.pdf Form and Instruction

Information Collection (IC) Details

View Information Collection (IC)

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:

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_EO revision.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 %

	Approved	Previously Approved
Annual Number of Responses for this IC	859,000	859,000
Annual IC Time Burden (Hours)	386,550	386,550
Annual IC Cost Burden (Dollars)	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.

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