Va Form 10-10ez - Application For Health Benefits - Department Of Veterans Affairs Page 4
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5SOCIAL SECURITY NUMBER
(Last, First, Middle)
VETERAN'S NAME
APPLICATION FOR HEALTH BENEFITS, Continued
SECTION II - INSURANCE INFORMATION (Use a separate sheet for additional information)
(Including coverage
1. ARE YOU COVERED BY HEALTH INSURANCE?
2. HEALTH INSURANCE COMPANY NAME, ADDRESS AND TELEPHONE NUMBER
through a spouse or another person)
YES
NO
3. NAME OF POLICY HOLDER
4. POLICY NUMBER
5. GROUP CODE
NO
YES
6. ARE YOU ELIGIBLE FOR MEDICAID?
7A. EFFECTIVE DATE
7. ARE YOU ENROLLED IN MEDICARE HOSPITAL INSURANCE PART A?
(mm/dd/yyyy)
8A. EFFECTIVE DATE
8. ARE YOU ENROLLED IN MEDICARE HOSPITAL INSURANCE PART B?
(mm/dd/yyyy)
9. NAME EXACTLY AS IT APPEARS ON YOUR MEDICARE CARD
10. MEDICARE CLAIM NUMBER
(Check one)
(Check One)
11. IS NEED FOR CARE DUE TO ON THE JOB INJURY?
12. IS NEED FOR CARE DUE TO ACCIDENT?
YES
NO
YES
NO
SECTION III - EMPLOYMENT INFORMATION
1. VETERAN'S EMPLOYMENT
1A. COMPANY NAME, ADDRESS AND TELEPHONE NUMBER
(Check one)
STATUS
FULL TIME
NOT EMPLOYED
If employed or retired,
PART TIME
complete item 1A
RETIRED
Date of retirement
(mm/dd/yyyy)
2. SPOUSE'S EMPLOYMENT
2A. COMPANY NAME, ADDRESS AND TELEPHONE NUMBER
(Check one)
STATUS
FULL TIME
NOT EMPLOYED
If employed or retired,
complete item 2A
PART TIME
RETIRED
Date of retirement
(mm/dd/yyyy)
SECTION IV - MILITARY SERVICE INFORMATION
1. LAST BRANCH OF SERVICE
1A. LAST ENTRY DATE
1B. LAST DISCHARGE DATE
1C. DISCHARGE TYPE
1D. MILITARY SERVICE NUMBER
2. CHECK YES OR NO
YES
NO
YES
NO
E1. ARE YOU RECEIVING DISABILITY RETIREMENT PAY INSTEAD OF
A. ARE YOU A PURPLE HEART AWARD RECIPIENT?
VA COMPENSATION?
F. WERE YOU EXPOSED TO ENVIRONMENTAL CONTAMINANTS WHILE
B. ARE YOU A FORMER PRISONER OF WAR?
SERVING IN SW ASIA DURING THE GULF WAR?
G. WERE YOU EXPOSED TO AGENT ORANGE WHILE SERVING IN
C. DO YOU HAVE A VA SERVICE-CONNECTED RATING?
VIETNAM?
%
C1. IF YES, WHAT IS YOUR RATED PERCENTAGE?
H. WERE YOU EXPOSED TO RADIATION WHILE IN THE MILITARY?
I. DID YOU RECEIVE NOSE AND THROAT RADIUM TREATMENTS
D. DID YOU SERVE IN COMBAT AFTER 11/11/1998?
WHILE IN THE MILITARY?
E. WAS YOUR DISCHARGE FROM MILITARY FOR A DISABILITY INCURRED OR
J. DO YOU HAVE A SPINAL CORD INJURY?
AGGRAVATED IN THE LINE OF DUTY?
SECTION V - PAPERWORK REDUCTION ACT AND PRIVACY ACT INFORMATION
The Paperwork Reduction Act of 1995 requires us to notify you that this information collection is in accordance with the
clearance requirements of Section 3507 of the Paperwork Reduction Act of 1995. We may not conduct or sponsor, and
you are not required to respond to, a collection of information unless it displays a valid OMB number. We anticipate that
the time expended by all individuals who must complete this form will average 45 minutes. This includes the time it will
take to read instructions, gather the necessary facts and fill out the form.
Privacy Act Information: VA is asking you to provide the information on this form under 38 U.S.C. Sections 1705,
1710, 1712, and 1722 in order for VA to determine your eligibility for medical benefits. Information you supply may be
verified through a computer-matching program. VA may disclose the information that you put on the form as permitted
by law. VA may make a "routine use" disclosure of the information as outlined in the Privacy Act systems of records
notices and in accordance with the VHA Notice of Privacy Practices. You do not have to provide the information to VA,
but if you don't, VA may be unable to process your request and serve your medical needs. Failure to furnish the
information will not have any affect on any other benefits to which you may be entitled. If you provide VA your Social
Security Number, VA will use it to administer your VA benefits. VA may also use this information to identify veterans
and persons claiming or receiving VA benefits and their records, and for other purposes authorized or required by law.
VA FORM
10-10EZ
PAGE 2
FEB 2005
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