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

OMB 2900-0091

OMB 2900-0091

Non-substantive updates have been made to VA Forms 10-10EZ and 10-10EZR to bring these forms into compliance with the MISSION Act of 2018. The forms collect information to enroll for health care 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 or yearly financial updates. A signed Non-substantive Change Memorandum has been added to the supplementary documents section.

The latest form for VA Health Benefits: Application, Update, Hardship Determination - VA Forms 10-10EZ,10-10EZR and 10-10HS expires 2020-12-31 and can be found here.

All Historical Document Collections
Reinstatement with change of a previously approved collection 2021-02-17
Approved with change
No material or nonsubstantive change to a currently approved collection 2019-10-01
Approved without change
No material or nonsubstantive change to a currently approved collection 2018-07-10
Approved without change
Reinstatement with change of a previously approved collection 2017-08-28
Approved with change
No material or nonsubstantive change to a currently approved collection 2014-11-24
Approved without change
No material or nonsubstantive change to a currently approved collection 2014-07-03
Approved with change
No material or nonsubstantive change to a currently approved collection 2014-06-20
Approved with change
Revision of a currently approved collection 2013-11-05
Approved without change
Extension without change of a currently approved collection 2013-02-14
Approved without change
Revision of a currently approved collection 2009-11-25
Preapproved
Revision of a currently approved collection 2009-04-23
Approved without change
No material or nonsubstantive change to a currently approved collection 2008-07-10
Approved without change
Extension without change of a currently approved collection 2007-06-06
Comment filed on proposed rule and continue
Revision of a currently approved collection 2004-12-28
Approved with change
Revision of a currently approved collection 2004-02-25
Approved without change
No material or nonsubstantive change to a currently approved collection 2003-03-18
Approved without change
Revision of a currently approved collection 2002-01-18
Approved without change
Reinstatement with change of a previously approved collection 1998-08-24
Approved without change
Revision of a currently approved collection 1997-08-13
Approved without change
Revision of a currently approved collection 1994-07-05
Approved without change
Reinstatement with change of a previously approved collection 1992-09-18
Approved without change
Revision of a currently approved collection 1987-07-15
Approved without change
Revision of a currently approved collection 1984-08-09
Approved without change
Reinstatement with change of a previously approved collection 1982-09-03
Approved with change
No material or nonsubstantive change to a currently approved collection 1980-11-14
Approved without change
Revision of a currently approved collection 1977-06-24
OMB Details

Application and Renewal for Health Benefits

Federal Enterprise Architecture: Health - Health Care Services

Form VA Form 10-10HSRequest for Hardship Determinationwww.va.gov/vaforms/medical/pdf/vha-10-10HS.pdfForm and instruction

Review document collections for all forms, instructions, and supporting documents - including paper/printable forms.


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