Fill VA Form 10-10EZ online
Instructions and Enrollment Application for Health Benefits
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VA Form 10-10EZ in short
VA Form 10-10EZ is the application veterans use to enroll in VA health care. VA says you must be enrolled to get care at VA facilities or to have VA cover care from an approved community provider. You can apply online, by phone, by mail or in person.
| Issued by | U.S. Department of Veterans Affairs (VA), Veterans Health Administration |
|---|---|
| Current version | Rev. February 2025 (checked 2026-10-25) |
| Who fills it in | Veterans applying for VA health care. The veteran signs, or a person the veteran has given power of attorney. Veterans already enrolled who need to update their details use VA Form 10-10EZR instead. |
| Who receives it | VA's Health Eligibility Center, which decides eligibility and enrollment priority. |
| Where to send it | Mail the original application and supporting papers to: Health Eligibility Center, PO Box 5207, Janesville, WI 53547-5207. You can also bring a signed form to a VA medical center or clinic, apply by phone at 877-222-8387, or apply online on VA.gov. |
| Deadline | No general deadline. Section I of the instructions notes that a veteran discharged for a disability incurred or aggravated in the line of duty can receive VA care for the 12 months after discharge. |
| Official links | Official page · Official PDF |
How to fill out VA Form 10-10EZ, line by line
| Section I | Type of benefit Choose Enrollment for the full VA medical benefits package, or Registration if you only need care under a special authority, such as care for a service-connected condition. Registration applicants complete Sections I to III only. |
| Section I, items 1 to 16 | General information Name, preferred name, Social Security number, date and place of birth, mailing and home address, marital status, next of kin, emergency contact, preferred VA facility and whether VA should contact you to book a first appointment. |
| Section II | Military service and exposures Branch, entry and discharge dates, discharge type, Purple Heart, prisoner of war, combat service and Gulf War service. Then answer the exposure questions with approximate month and year ranges. You may attach your DD214 to speed up processing. |
| Section III | Insurance List every health insurer that covers you, including coverage through a spouse, plus Medicaid and Medicare Part A details. |
| Section IV | Dependents Spouse and qualifying children, with dates of birth and Social Security numbers. The instructions explain which children count. |
| Section V | Employment Your employment status, retirement date, and employer name, address and phone if you are employed or retired. |
| Section VI | Financial disclosure choice Choose whether to provide household income and expenses for last calendar year. The instructions say only nonservice-connected and 0% noncompensable service-connected veterans must complete this to decide eligibility, with listed exceptions. |
| Sections VII and VIII | Income and deductible expenses Gross income from work, net business or farm income, and other income for you, your spouse and a child. Then non-reimbursed medical expenses, funeral costs for a spouse or child, and your own education costs from last year. |
| Signature | Signature of applicant and date Sign in ink and date the form. If you sign with an X, two people you know must witness it and sign and print their names. |
Common mistakes to avoid
- Forgetting to sign and date the form. The instructions say VA will return an unsigned or undated form.
- Signing with an X without two witnesses who also sign and print their names.
- Using this form to update an existing enrollment. VA says to use VA Form 10-10EZR for that.
- Leaving out insurance coverage you have through a spouse or significant other.
- Reporting income that the instructions say not to report, such as SSI, welfare payments, loans or income tax refunds.
- Skipping the financial sections when they apply. VA says it is not enrolling applicants who decline to give financial information unless they have other qualifying eligibility factors.
- Sending a power of attorney signature without a copy of the power of attorney document.
Questions about VA Form 10-10EZ
Can I apply for VA health care online?
Yes. VA's form page says you can apply online instead of filling out and sending the paper form. You can also apply by phone at 877-222-8387.
Where do I mail VA Form 10-10EZ?
To the Health Eligibility Center, PO Box 5207, Janesville, WI 53547-5207.
Do I have to give my income?
Not always. The instructions list groups who do not have to disclose income, such as veterans receiving VA service-connected compensation. VA says that if you are not eligible based on other factors, it will need the information to decide your application.
Which year's income do I report?
The previous calendar year, for you, your spouse and your dependent children.
Should I attach my DD214?
The instructions say that if you do not already receive VA benefits, you may attach a copy of your discharge papers, such as a DD214, to speed up processing.
What is the difference between 10-10EZ and 10-10EZR?
VA Form 10-10EZ is for applying. VA Form 10-10EZR is for veterans already enrolled who need to update personal, insurance, financial or military information.
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Checked against the official sources on 2026-10-25. PDF Editor Hub is not affiliated with the U.S. Department of Veterans Affairs or any government agency. This page is general information, not legal or tax advice.