Va Form 10-10ez - Application For Health Benefits - Department Of Veterans Affairs (Page 2 of 5) in pdf

Step 2: Completing your application ...

Review the table in Step 1 to find out what sections you should complete.

Answer all questions in those 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. For each question that you need more room, 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. 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 should 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 status as a Purple Heart Medal recipient, we will ask you to provide VA a copy of your DD-214 or other military service

records or orders indicating you were awarded the medal. To reduce processing time, you may submit a copy of this documentation

with your signed application.

Section VI - Financial Disclosure.

The financial assessment is used to determine whether certain veterans qualify for cost-free

health care services for their nonservice-connected conditions and to assign their priority for enrollment. You should review the table

in Step 1 to see if your eligibility for health care benefits requires or may be based on a financial assessment.

If your financial information is used to determine your priority for enrollment and you choose not to disclose this information, you

must agree to make copayments. However, please be aware that even if you agree to pay copayments, you may not be eligible for

enrollment and other health care benefits for your nonservice-connected conditions, if you are placed in a priority group that is not

eligible for enrollment.

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 copayments for treatment of your nonservice-connected conditions. If a financial assessment is used to determine your

eligibility for travel assistance, and you do not disclose your financial information, you will not be eligible for this benefit for your

nonservice-connected conditions.

Section VII - Dependent Information.

Use a separate sheet of paper for additional dependent children.

You may count your spouse as your dependent even if you did not live together, as long as you contributed $600 or more in support

last calendar year.

You may count your biological children, adopted children, and stepchildren as dependents. But these children must be unmarried and

under the age of 18, or be at least 18 but under 23 and attending high school, college or vocational school on a full or part-time basis,

or have become permanently unable to support themselves before reaching the age of 18.

Count child support contributions even if not paid in regular set amounts. Contributions can include tuition payments or payments of

medical bills.

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

Use a separate sheet of paper for additional dependent children.

Report: gross annual income from employment, except for income from your farm, ranch, property or business, including

information about 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

Report: net income from your farm, ranch, property or business.

Report: 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

Do Not Report: Welfare, Supplemental Security Income (SSI) and need-based payments from a government agency, profit from the

occasional sale of property, income tax refunds, reinvested interest on Individual Retirement Accounts (IRAs), scholarships and grants

for school attendance, disaster relief payment or proceeds of casualty insurance, loans, Agent Orange and Alaska Native Claim

Settlement Acts Income and payments to foster parents.

Section IX - Previous Calendar Year Deductible Expenses.

Report nonreimbursed medical expenses paid by you or

your spouse. Include expenses for medical and dental care, drugs, eyeglasses, Medicare, medical insurance premiums and other health

care expenses paid by you for dependents and persons for whom you have a legal or moral obligation to support. Do not list expenses

if you expect to receive reimbursement from insurance or other sources.

Section X - Previous Calendar Year Net Worth.

Use a separate sheet of paper for additional dependent children.

Your net worth is the market value of all the interest and rights you have in any kind of property. However net worth does not include

your single-family residence and a reasonable lot area surrounding it. It also does not include the personal things you use every day

like your vehicle, clothing and furniture.

Step 3: Submitting your application ...

What do I do when I have finished my application?

Read Section V, Consent to Copayments, Section XI, Paperwork and Privacy Act Information and Section XII, Assignment of

Benefits.

Make sure you sign and date VA Form 10-10EZ in Section XII. You or an individual to whom you have delegated your Power of

Attorney must sign and date the form. If you sign with an "X", then you must have 2 people you know witness you as you sign. They

must then sign the form and print their names. If the form is not signed and dated appropriately, VA will return it for you to

complete. This will result in a delay in processing your application.

Attach any continuation sheets and necessary material to your application.

Where do I send my application?

Mail the original application with a copy of your supporting materials to your local VA

care facility. You can find the address in your local telephone book, by calling toll-free 1-877-222-VETS (8387), or on the Internet

VA FORM

10-10EZ

FEB 2005

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

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