Fill out an Application for Health Benefits (VA Form EZ). Download VA Form EZ. You or someone acting as your power of attorney. Which sections of VA Form EZ should you complete? Definitions of terms used on this form. If you desire a health care appointment, contact the Enrollment . Complete and submit the VA Form EZ to apply for enrollment in the VA health care system.
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To navigate this form, use the buttons provided on each page. Therefore, the form must be completed in a single session.
VA Form 10-10EZ – Application for Medical Benefits (Enroll)
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Click here to obtain a free copy of the Adobe Acrobat Reader software. Enter your search text Button to start search. This is a “smart” form in that it will route you around sections 110 the form you do not have to complete which is based on the information you enter.
10ze If you the applicant are unable to sign the form, two people known to the applicant may witness the applicant making 10wz “X” on the form. The witnesses must also sign the form and print their names. 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.
We will begin processing the application upon receipt of the signed form. Additionally, the online form limits the amount of time your browser can remain idle. This will result in a delay in processing the application.
VA Form EZ – Application for Medical Benefits (Enroll) (Health Eligibility Center)
If a new window does not appear, please check for a pop-up blocker. If you have a pop-up blocker on your computer, you should adjust it to allow a pop-up from this site or disable it while completing this form. Do not use the browser ” Back ” and ” Forward ” buttons. You will be provided an opportunity to review and change your information prior to 100. You the applicant must sign and date the printed copy and mail or fax it to the selected VA Facility.
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Typically, veterans who have NOT previously enrolled or applied for VA health care benefits 10z use this form. Before beginning the online submission process, we suggest viewing or printing the EZ to assist you in gathering all the information required to complete it.
If you have delegated someone else to sign the form, we must receive a copy of the Power of Attorney. If the form is not signed and dated, VA will return it to the applicant to complete.
Instructions for Completing VA Form EZ On-Line Before beginning the online submission process, we suggest viewing or printing the EZ to assist you in gathering all the information required to complete it. If you do not see the words “Print test successful”you should check to make sure that Acrobat Reader has been installed. I have read this page and want to go to the Online Submission Form. Because of the sensitive nature of the information requested, the information is not saved in your computer or on our web server.