VA Form 10-10EZ - Application for Medical Benefits (Enroll)
The primary purpose of this form is to request enrollment in the VA Health Care System (Apply for Medical Benefits). Typically, veterans who have NOT previously enrolled or applied for VA health care benefits should use this form.
Before beginning the online submission process, we suggest viewing or printing the 10-10EZ to assist you in gathering all the information required to complete it. This is a "smart" form in that it will route you around sections of the form you do not have to complete which is based on the information you enter. To navigate this form, use the buttons provided on each page. Do not use the browser "Back" and "Forward" buttons.
Because of the sensitive nature of the information requested, the information is not saved in your computer or on our web server. Therefore, the form must be completed in a single session. Additionally, the online form limits the amount of time your browser can remain idle. If you stay on a single page for more than 20 minutes, a window will be displayed asking if you want to continue or close the online form. Click the "Continue" button promptly to avoid closing your form and erasing the information you have entered.
You will be provided an opportunity to review and change your information prior to submission. You (the applicant) must sign and date the printed copy and mail or fax it to the selected VA Facility. If you have delegated someone else to sign the form, we must receive a copy of the
Power of Attorney. If you
(the applicant) are unable to sign the form, two people known to the applicant may witness the applicant making an "X" on the form. The witnesses must also sign the form and print their names. If the form is not signed and dated, VA will return it to the applicant to complete. This will result in a delay in processing the application. We will begin processing the application upon receipt of the signed form.
You can also submit VA Form 10-10EZ by mailing or faxing the completed (signed and dated) form to the VA Medical Center or Clinic of your choice. Click here for a listing of VA Medical Facilities and Clinics.
There are several other ways to enroll:
- You can enroll in person at any VA Medical Center or Clinic.
- You can obtain enrollment assistance by calling VA's Health Benefits Service Center, Monday through Friday between the hours of 8:00 AM and 8:00 PM (EST) at 877-222-VETS.
- You can also enroll by mailing or faxing the completed Form 10-10EZ to the Medical Center or Clinic of your choice.
- You can obtain additional assistance by contacting your State or County Veterans Service Officer. For telephone listings please consult the Government Section (blue pages) of your local phone book under "United States Offices", then look for "Veterans Affairs" or check our VSO Listing.
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Click this link to run a Printing Test to ensure that you will be able to print your completed form. If a new window does not appear, please check for a pop-up blocker. If you do not see the words "Print test successful", you should check to make sure that Acrobat Reader has been installed.
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