Va Form 10-10ez - Application For Health Benefits - Department Of Veteran Affairs Page 4

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APPLICATION FOR HEALTH BENEFITS
(Last, First, Middle)
VETERAN'S NAME
SOCIAL SECURITY NUMBER
Continued
SECTION III - INSURANCE INFORMATION (Use a separate sheet for additional information)
(include coverage through spouse or other person)
1. ENTER YOUR HEALTH INSURANCE COMPANY NAME, ADDRESS AND TELEPHONE NUMBER
2. NAME OF POLICY HOLDER
3. POLICY NUMBER
4. GROUP CODE
5. ARE YOU
6A. ARE YOU ENROLLED IN MEDICARE
ELIGIBLE FOR
HOSPITAL INSURANCE PART A?
MEDICAID?
YES
NO
YES
NO
6B. EFFECTIVE DATE
(mm/dd/yyyy)
SECTION IV - DEPENDENT INFORMATION (Use a separate sheet for additional dependents)
(Last, First, Middle Name)
(Last, First, Middle Name)
1. SPOUSE'S NAME
2. CHILD'S NAME
(mm/dd/yyyy)
1A. SPOUSE'S SOCIAL SECURITY NUMBER
2A. CHILD'S DATE OF BIRTH
2B. CHILD'S SOCIAL SECURITY NO.
(mm/dd/yyyy)
1C. SPOUSE SELF-IDENTIFIED
2C. DATE CHILD BECAME YOUR DEPENDENT
1B. SPOUSE'S DATE OF BIRTH
(mm/dd/yyyy)
GENDER IDENTITY
MALE
FEMALE
(mm/dd/yyyy)
(Check one)
1D. DATE OF MARRIAGE
2D. CHILD'S RELATIONSHIP TO YOU
SON
DAUGHTER
STEPSON
STEPDAUGHTER
(Street, City, State, ZIP
2E. WAS CHILD PERMANENTLY AND TOTALLY DISABLED BEFORE THE
1E. SPOUSE'S ADDRESS AND TELEPHONE NUMBER
if different from Veteran's)
AGE OF 18?
YES
NO
2F. IF CHILD IS BETWEEN 18 AND 23 YEARS OF AGE, DID CHILD ATTEND SCHOOL
LAST CALENDAR YEAR?
YES
NO
3. IF YOUR SPOUSE OR DEPENDENT CHILD DID NOT LIVE WITH YOU LAST
2G. EXPENSES PAID BY YOUR DEPENDENT CHILD FOR COLLEGE, VOCATIONAL
YEAR, DID YOU PROVIDE SUPPORT?
(e.g., tuition, books, materials)
REHABILITATION OR TRAINING
YES
NO
SECTION V - EMPLOYMENT INFORMATION
(Check one).
1B. DATE OF RETIREMENT
1A. VETERAN'S EMPLOYMENT STATUS
FULL TIME
PART TIME
NOT EMPLOYED
RETIRED
1D. COMPANY ADDRESS
1C. COMPANY NAME.
1E. COMPANY PHONE NUMBER
(Complete if employed or retired)
(Complete if employed or retired)
(Complete if employed or retired -Street, City, State, ZIP )
(Include area code)
SECTION VI - PREVIOUS CALENDAR YEAR GROSS ANNUAL INCOME OF VETERAN, SPOUSE AND DEPENDENT CHILDREN
(Use a separate sheet for additional dependents)
(wages, bonuses, tips,
1. GROSS ANNUAL INCOME FROM EMPLOYMENT
VETERAN
SPOUSE
CHILD 1
etc.)
EXCLUDING INCOME FROM YOUR FARM, RANCH, PROPERTY OR
$
$
$
BUSINESS
2. NET INCOME FROM YOUR FARM, RANCH, PROPERTY OR BUSINESS
$
$
$
(e.g., Social Security, compensation,
3. LIST OTHER INCOME AMOUNTS
$
$
$
pension interest, dividends)
EXCLUDING WELFARE.
SECTION VII - PREVIOUS CALENDAR YEAR DEDUCTIBLE EXPENSES
(e.g., payments for doctors, dentists, medications,
1. TOTAL NON-REIMBURSED MEDICAL EXPENSES PAID BY YOU OR YOUR SPOUSE
$
Medicare, health insurance, hospital and nursing home) VA will calculate a deductible and the net medical expenses you may claim.
$
2. AMOUNT YOU PAID LAST CALENDAR YEAR FOR FUNERAL AND BURIAL EXPENSES (INCLUDING PREPAID BURIAL EXPENSES)
(Also enter spouse or child's information in Section VI.)
FOR YOUR DECEASED SPOUSE OR DEPENDENT CHILD
(e.g., tuition, books,
$
3. AMOUNT YOU PAID LAST CALENDAR YEAR FOR YOUR COLLEGE OR VOCATIONAL EDUCATIONAL EXPENSES
fees, materials) DO NOT LIST YOUR DEPENDENTS' EDUCATIONAL EXPENSES.
VA FORM
10-10EZ
PAGE 2
APR 2017

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