Va Form 10-10ez - Application For Health Benefits - Department Of Veteran Affairs Page 3

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OMB Approved No. 2900-0091
Estimated Burden Avg. 30 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)
1B. PREFERRED NAME
2. MOTHER'S MAIDEN NAME
1A. VETERAN'S NAME
(You may check more than one.
3A. BIRTH SEX
3B. SELF-IDENTIFIED
4. ARE YOU SPANISH,
5. WHAT IS YOUR RACE?
6. SOCIAL SECURITY NO.
Information is required for statistical purposes only.)
GENDER IDENTITY
HISPANIC,OR LATINO?
MALE
MALE
YES
ASIAN
AMERICAN INDIAN OR ALASKA NATIVE
BLACK OR AFRICAN AMERICAN
WHITE
FEMALE
FEMALE
NO
NATIVE HAWAIIAN OR OTHER PACIFIC ISLANDER
(mm/dd/yyyy)
(City and State)
7. VA CLAIM NUMBER
8A. DATE OF BIRTH
8B. PLACE OF BIRTH
9. RELIGION
(Street)
10A. PERMANENT ADDRESS
10B. CITY
10C. STATE
10D. ZIP CODE
10E.COUNTY
(Include area code)
(Include area code)
10F. HOME TELEPHONE NO.
10G. MOBILE TELEPHONE NO.
10H. E-MAIL ADDRESS
(Street)
11A. RESIDENTIAL ADDRESS
11B. CITY
11C. STATE
11D. ZIP CODE
11E.COUNTY
12. TYPE OF BENEFIT(S) APPLYING FOR
13. CURRENT MARTIAL STATUS
(You may check more than one)
ENROLLMENT/HEALTH SERVICES
DENTAL
MARRIED
NEVER MARRIED
SEPARATED
WIDOWED
DIVORCED
14A. NEXT OF KIN NAME
14B. NEXT OF KIN ADDRESS
14C. NEXT OF KIN RELATIONSHIP
14D. NEXT OF KIN TELEPHONE NO.
14E. NEXT OF KIN WORK TELEPHONE NO.
15. DESIGNEE - INDIVIDUAL TO RECEIVE POSSESSION OF YOUR PERSONAL
(Include Area Code)
(Include Area Code)
PROPERTY LEFT ON PREMISES UNDER VA CONTROL AFTER YOUR
(Note: This does not constitute a
DEPARTURE OR AT THE TIME OF DEATH
will or transfer of title)
16. I AM ENROLLING TO OBTAIN MINIMUM
18. WOULD YOU LIKE FOR VA TO
17. WHICH VA MEDICAL CENTER OR OUTPATIENT CLINIC DO YOU PREFER?
ESSENTIAL COVERAGE UNDER THE
CONTACT YOU TO SCHEDULE
(for listing of facilities visit )
AFFORDABLE CARE ACT
YOUR FIRST APPOINTMENT?
YES
NO
YES
NO
SECTION II - MILITARY SERVICE INFORMATION
1A. LAST BRANCH OF SERVICE
1B. LAST ENTRY DATE
1C. FUTURE DISCHARGE DATE
1D. LAST DISCHARGE DATE
1E. DISCHARGE TYPE
1F. MILITARY SERVICE NUMBER
(Check yes or no)
YES
NO
YES
NO
2. MILITARY HISTORY
A. ARE YOU A PURPLE HEART AWARD RECIPIENT?
G. DO YOU HAVE A VA SERVICE-CONNECTED RATING?
B. ARE YOU A FORMER PRISONER OF WAR?
IF "YES", WHAT IS YOUR RATED PERCENTAGE
%
C. DID YOU SERVE IN A COMBAT THEATER OF OPERATIONS AFTER
H. DID YOU SERVE IN VIETNAM BETWEEN JANUARY 9, 1962
11/11/1998?
AND MAY 7, 1975?
D. WERE YOU DISCHARGED OR RETIRED FROM MILITARY FOR A
I. WERE YOU EXPOSED TO RADIATION WHILE IN THE
DISABILITY INCURRED IN THE LINE OF DUTY?
MILITARY?
E. ARE YOU RECEIVING DISABILITY RETIREMENT PAY INSTEAD OF
J. DID YOU RECEIVE NOSE AND THROAT RADIUM
VA COMPENSATION?
TREATMENTS WHILE IN THE MILITARY?
K. DID YOU SERVE ON ACTIVE DUTY AT LEAST 30 DAYS AT
F. DID YOU SERVE IN SW ASIA DURING THE GULF WAR BETWEEN
CAMP LEJEUNE FROM AUGUST 1, 1953 THROUGH
AUGUST 2, 1990 AND NOVEMBER 11, 1998?
DECEMBER 31, 1987?
VA FORM
10-10EZ
PREVIOUS EDITIONS OF THIS FORM ARE NOT TO BE USED
PAGE 1
APR 2017

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