Va Form 10-10ez - Application For Health Benefits - Department Of Veteran Affairs (Page 2 of 6) in pdf

Continued ...

Section VI - Dependent Information:

Your spouse and dependent social security number(s) are required so we can verify their

financial and insurance information through a computer-matching program.

Section VII - Previous Calendar Year Gross Annual Income of Veteran, Spouse and Dependent Children:

Answer

applicable questions

Section VIII - Previous Calendar Year Deductible Expenses:

Answer applicable questions

Section IX - Previous Calendar Year Net Worth:

Answer applicable questions

NOTE:

All other Veterans may wish to provide this financial assessment to determine, as applicable, their eligibility for cost-free

medication for their NSC conditions, beneficiary travel eligibility and/or waiver of the beneficiary travel deductible requirement.

Additional Information for Completing your application ...

Answer all questions in the appropriate sections. If you need more space to answer a question, attach a sheet of paper to the form

containing your name and Social Security Number. If you need more room to respond to a question, write "Continuation of Item"

and write the section and question number.

Section II - Insurance Information.

Include information for all health insurance policies that cover you, this includes coverage that is 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.

Section IV - Military Service Information.

If you are not currently receiving benefits from VA, you may attach a copy of your discharge or separation papers from the

military (such as DD-214 or, for WWII veterans, a "WD" Form), with your signed application to expedite processing of your

application.

If you indicate that you received a Purple Heart Medal, we will check our records for confirmation of your status. If we are

unable to confirm your Purple Heart status, we will ask you to provide VA a copy of your DD-214 or other military service

records or orders indicating your award. To reduce processing time, you may submit a copy of this documentation with your

application.

Section V - Financial Disclosure.

You are not required to disclose your financial information; however, VA is not currently enrolling new applicants who decline

to provide their financial information unless they have other qualifying eligibility factors. If a financial assessment is not used to

determine your priority for enrollment you may choose not to disclose your information and agree to make co-payments for

treatment of your NSC conditions. If a financial assessment is used to determine your eligibility for cost-free medication, travel

assistance or waiver of deductible, and you do not disclose your financial information, you may not be eligible for these benefits.

Section VI - Dependent Information - Include the following:

•

Your spouse even if you did not live together, as long as you contributed support last calendar year.

•

Your biological children, adopted children, and stepchildren who are unmarried and under the age of 18, or at least 18 but

under 23 and attending high school, college or vocational school (full or part-time), or became permanently unable to support

themselves before age 18.

•

Child support contributions. Contributions can include tuition or clothing payments or payments of medical bills.

Section VII - Previous Calendar Year Gross Annual Income of Veteran, Spouse and Dependent Children.

Report:

•

Gross annual income from employment, except for income from your farm, ranch, property or business. Include your wages,

bonuses, tips, severance pay and other accrued benefits and your child's income information if it could have been used to pay

your household expenses.

•

Net income from your farm, ranch, property, or business.

•

Other income amounts, including retirement and pension income, Social Security Retirement and Social Security Disability

income, compensation benefits such as VA disability, unemployment, Workers and black lung, cash gifts, interest and

dividends, including tax exempt earnings and distributions from Individual Retirement Accounts (IRAs) or annuities.

10-10EZ

VA FORM

FEB 2011

Va Form 10-10ez - Application For Health Benefits - Department Of Veteran Affairs Page 2

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