10 – 10EZ PDF

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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Do not use the browser ” Back ” and ” Forward ” buttons. 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.

You must have the latest version of Adobe Acrobat Reader on your computer to save or print the forms. Click this link to run a Printing Test to ensure that you will be able to print your completed form. 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. If a new window does not appear, please check for a pop-up blocker.


You the applicant must sign and date the printed copy and mail or fax it to the selected VA Facility. Enter your search text Button to start search.

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 10wz. We will begin processing the application upon receipt of the signed form. This will result in a delay in processing the application.

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.

Click here to obtain a free copy of the Adobe Acrobat Reader software. Click the “Continue” button promptly to avoid closing your form and erasing the information you have entered.

I have read this page and want to go to the Online Submission Form. 110

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 your browser does not have scripting enabled, or it does not support it.

VA Form EZ – Application for Medical Benefits (Enroll) (Health Eligibility Center)

You 100ez be provided an opportunity to review and change your information prior to submission. 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.


Additionally, the online form limits the amount of time your browser can remain idle. Therefore, the form must be completed in a single session. Typically, veterans who have NOT previously enrolled or applied for VA health care benefits should use this 10es.

If you do not see the words “Print test successful”you should check to make sure that Acrobat Reader has been installed.

To navigate this form, use the buttons provided on each page. If the form is not signed and dated, VA will return it to the applicant to complete.

If you have delegated someone else to sign the form, we must receive 1e0z copy of the Power of Attorney. Because of the sensitive nature of the information requested, the information is not saved in your computer or on our web server.

The witnesses must also sign the form and print their names. The forms may not function correctly.