Va Form 10-10ez - Application For Health Benefits - Department Of Veteran Affairs Page 4
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6OMB Approved No. 2900-0091
Estimated Burden Avg. 45 min.
APPLICATION FOR HEALTH BENEFITS
SECTION I - GENERAL INFORMATION
Federal law provides criminal penalties, including a fine and/or imprisonment for up to 5 years, for concealing a material fact
or making a materially false statement. (See 18 U.S.C. 1001)
(Last, First, Middle Name)
2. OTHER NAMES USED
3. MOTHER'S MAIDEN NAME
4. GENDER
1. VETERAN'S NAME
MALE
FEMALE
(You may check more than one.) (Information is required for statistical purposes only.)
5. ARE YOU SPANISH, HISPANIC, OR LATINO?
6. WHAT IS YOUR RACE?
AMERICAN INDIAN OR ALASKA NATIVE
BLACK OR AFRICAN AMERICAN
YES
NO
ASIAN
WHITE
NATIVE HAWAIIAN OR OTHER PACIFIC ISLANDER
7. SOCIAL SECURITY NUMBER
8. VA CLAIM NUMBER
(mm/dd/yyyy)
9. DATE OF BIRTH
(City and State)
10. RELIGION
9A. PLACE OF BIRTH
(Street)
11A. CITY
11B. STATE
11C. ZIP CODE
11. PERMANENT ADDRESS
(Include area code)
11D. COUNTY
11E. HOME TELEPHONE NUMBER
11F. E-MAIL ADDRESS
(Include area code)
11G. CELLULAR TELEPHONE NUMBER
12. TYPE OF BENEFIT(S) APPLYING FOR
(You may check more than one)
ENROLLMENT/HEALTH SERVICES
DENTAL
13. WHICH VA MEDICAL CENTER OR OUTPATIENT CLINIC DO YOU PREFER?
14. DO YOU WANT AN APPOINTMENT WITH A VA DOCTOR OR PROVIDER AS SOON
(for listing of facilities visit )
AS ONE BECOMES AVAILABLE?
I am only enrolling in case I need care in the future.
YES
NO
(Check one)
15. CURRENT MARITAL STATUS
MARRIED
NEVER MARRIED
SEPARATED
WIDOWED
DIVORCED
UNKNOWN
16. NAME, ADDRESS AND RELATIONSHIP OF NEXT OF KIN
(Include area code)
16A. NEXT OF KIN'S HOME TELEPHONE NUMBER
(Include area code)
16B. NEXT OF KIN'S WORK TELEPHONE NUMBER
17. NAME, ADDRESS AND RELATIONSHIP OF EMERGENCY CONTACT (if different than 16)
17A. EMERGENCY CONTACT'S HOME TELEPHONE NUMBER
(Include area code)
17B. EMERGENCY CONTACT'S WORK TELEPHONE NUMBER
(Include area code)
SECTION II - INSURANCE INFORMATION (Use a separate sheet for additional information)
1. ENTER HEALTH INSURANCE COMPANY NAME, ADDRESS AND TELEPHONE NUMBER (include coverage through spouse or other person)
5. ARE YOU ELIGIBLE FOR MEDICAID?
2. NAME OF POLICY HOLDER
(mm/dd/yyyy)
3. POLICY NUMBER
4. GROUP CODE
5A. EFFECTIVE DATE
YES
NO
(mm/dd/yyyy)
6 ARE YOU ENROLLED IN MEDICARE HOSPITAL INSURANCE PART A?
6A. EFFECTIVE DATE
YES
NO
7. ARE YOU ENROLLED IN MEDICARE HOSPITAL INSURANCE PART B?
7A. EFFECTIVE DATE
(mm/dd/yyyy)
NO
YES
8. NAME EXACTLY AS IT APPEARS ON YOUR MEDICARE CARD
9. MEDICARE CLAIM NUMBER
10-10EZ
VA FORM
PAGE 1
PREVIOUS EDITIONS OF THIS FORM ARE NOT TO BE USED
FEB 2011
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