Va Form 10-10ez - Application For Health Benefits - Department Of Veterans Affairs Page 3
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5OMB Approved No. 2900-0091
Estimated Burden Avg. 45 min.
Expiration Date: 6/30/2007
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)
1. VETERAN'S NAME
(Last, First, Middle Name)
2. OTHER NAMES USED
3. MOTHER'S MAIDEN NAME
4. GENDER
MALE
FEMALE
5. ARE YOU SPANISH, HISPANIC, OR LATINO?
6. WHAT IS YOUR RACE?
(You may check more than one.) (Information is required for statistical purposes only.)
AMERICAN INDIAN OR ALASKA NATIVE
BLACK OR AFRICAN AMERICAN
YES
NO
ASIAN
WHITE
NATIVE HAWAIIAN OR OTHER PACIFIC ISLANDER
7. SOCIAL SECURITY NUMBER
(mm/dd/yyyy)
10. RELIGION
9. DATE OF BIRTH
(City and State)
8. CLAIM NUMBER
9A. PLACE OF BIRTH
(Street)
11. PERMANENT ADDRESS
11A. CITY
11B. STATE
11C. ZIP CODE
11D. COUNTY
11E. HOME TELEPHONE NUMBER
(Include area code)
11F. E-MAIL ADDRESS
(Include area code)
(Include area code)
11H. PAGER NUMBER
11G. CELLULAR TELEPHONE NUMBER
(You may check more than one)
12. TYPE OF BENEFIT(S) APPLIED FOR
HEALTH SERVICES
NURSING HOME
DOMICILIARY
DENTAL
13. IF APPLYING FOR HEALTH SERVICES OR ENROLLMENT, WHICH VA MEDICAL CENTER OR OUTPATIENT CLINIC DO YOU PREFER?
14. DO YOU WANT AN APPOINTMENT WITH A VA DOCTOR OR PROVIDER AS SOON AS ONE BECOMES
15. HAVE YOU BEEN SEEN AT A VA HEALTH CARE FACILITY?
AVAILABLE?
I am only enrolling in case I need care in the future.
YES
NO
YES,
LOCATION:
NO
(Check one)
16. CURRENT MARITAL STATUS
MARRIED
NEVER MARRIED
SEPARATED
WIDOWED
DIVORCED
UNKNOWN
(Include area code)
17. NAME, ADDRESS AND RELATIONSHIP OF NEXT OF KIN
17A. NEXT OF KIN'S HOME TELEPHONE NUMBER
(Include area code)
17B. NEXT OF KIN'S WORK TELEPHONE NUMBER
18. NAME, ADDRESS AND RELATIONSHIP OF EMERGENCY CONTACT
18A. EMERGENCY CONTACT'S HOME TELEPHONE NUMBER
(Include area code)
18B. EMERGENCY CONTACT'S WORK TELEPHONE NUMBER
(Include area code)
19. INDIVIDUAL TO RECEIVE POSSESSION OF YOUR PERSONAL PROPERTY LEFT ON PREMISES UNDER VA CONTROL AFTER YOUR DEPARTURE OR AT THE TIME OF DEATH. NOTE:
(Check one)
THIS DOES NOT CONSTITUTE A WILL OR TRANSFER OF TITLE
EMERGENCY CONTACT
NEXT OF KIN
VA FORM
10-10EZ
PAGE 1
FEB 2005
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