Va Form 10-10ezr - Heath Benefits Update Form - Department Of Veterans Affairs
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4INSTRUCTIONS FOR COMPLETING
HEALTH BENEFITS UPDATE FORM
Please Read Before You Start . . . What is VA Form 10-10EZR used for?
VA Form 10-10EZR is used by VA to update your personal, insurance, or financial information after you are enrolled.
Where can I get help filling out the form and if I have questions? This update form is available for
completion online at
You may use ANY of the following to request assistance:
• Ask VA to help you fill out the form by calling us at 1-877-222-VETS (8387).
• Contact the Enrollment Coordinator at your local VA health care facility.
• Contact a National or State Veterans Service Organization.
Definitions of terms used on this form:
SERVICE-CONNECTED (SC): A VA determination that an illness or injury was incurred or aggravated in the line of duty, in the
active military, naval or air service.
COMPENSABLE: A VA determination that a service-connected disability is severe enough to warrant monetary compensation.
NONCOMPENSABLE: A VA determination that a service-connected disability is not severe enough to warrant monetary
compensation.
NONSERVICE-CONNECTED (NSC): A Veteran who does not have a VA determined service-related condition.
SPOUSE: If you are certifying that a person is your spouse for the purpose of VA benefits, your marriage must be recognized by the
place where you and/or your spouse resided at the time of marriage, or where you and/or your spouse reside when you file your
claim (or at a later date when you become eligible for benefits) (38 U.S.C. 103(c)). Additional guidance on when VA recognizes
marriages is available at
ALL VETERANS MUST COMPLETE SECTIONS I, II, VI, and VII
Directions for Sections I - II:
Section I - General Information:
Answer all questions.
Section II - Insurance Information:
Include information for all health insurance companies that cover you, this includes
coverage provided through a spouse or significant other. If you have more than one health insurer, provide this information on a
separate sheet of paper and attach to the application. If you have access to a copier, attach a copy of your insurance cards, Medicare
card and/or Medicaid card (Medicaid is a federal/state health insurance program for certain low-income people). Bring these cards
with you to each health care appointment.
COMPLETE SECTION III only if you complete Sections IV:
Section III - Dependent Information:
Your spouse and dependent social security numbers(s) are required so we can verify
their financial information through a computer-matching program. You may count your spouse as your dependent even if you did not
live together, as long as you contributed support last calendar year. You may count your biological children, adopted children, and
stepchildren as dependents. These children must be unmarried and under the age of 18, or be at least 18 but under 23 and attending
high school, college or vocational school on a full or part-time basis, or have become permanently unable to support themselves
before reaching the age of 18.
Directions for Sections IV - V:
Veterans may provide a financial assessment to update their eligibility for cost-free medical services for their NSC conditions,
beneficiary travel eligibility, and/or waiver of the beneficiary travel deductible requirement.
Veterans rated 50-100% disabled due to SC conditions and Veterans receiving VA pension are not required to provide a financial
assessment.
Complete only the sections that apply to you; sign and date the form.
VA FORM
10-10EZR
APR 2017
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