Va Form 10-10ezr - Heath Benefits Update Form - Department Of Veterans Affairs Page 3
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4OMB Approved No. 2900-0091
Estimated Burden Avg. 15 min
Expiration Date: 01/17/2017
HEALTH BENEFITS UPDATE FORM
SECTION I - GENERAL INFORMATION
Federal law provides criminal penalties, including a fine and/or imprisonment, for any materially false, fictitious, or fraudulent statement or
representation. (See 18 U.S.C. 287 and 1001).
1A. VETERAN'S NAME (Last, First, Middle Name)
2. SOCIAL SECURITY NUMBER
(Last, First, Middle Name)
1B. VETERAN'S PREFERRED NAME
(Include area code)
4. DATE OF BIRTH (mm/dd/yyyy)
3A. BIRTH SEX
3B. SELF-IDENTIFIED GENDER IDENTITY
5. HOME TELEPHONE NUMBER
MALE
MALE
(Include area code)
FEMALE
FEMALE
6. MOBILE TELEPHONE NUMBER
(Street)
7A. PERMANENT ADDRESS
7B. CITY
7C. STATE
7D. ZIP CODE
7E. COUNTY
(Street)
8B. CITY
8A. RESIDENTIAL ADDRESS
8C. STATE
8D. ZIP CODE
8E. COUNTY
9. E-MAIL ADDRESS
10. CURRENT MARITAL STATUS
MARRIED
NEVER MARRIED
SEPARATED
WIDOWED
DIVORCED
SECTION II - 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
5. ARE YOU ELIGIBLE
2. NAME OF POLICY HOLDER
3. POLICY NUMBER
4. GROUP CODE
FOR MEDICAID?
YES
NO
(mm/dd/yyyy)
6. ARE YOU ENROLLED IN MEDICARE HOSPITAL INSURANCE PART A?
YES
NO
7. EFFECTIVE DATE
SECTION III - DEPENDENT INFORMATION (Use a separate sheet for additional dependents)
(Last, First, Middle Name)
(Last, First, Middle Name)
1. SPOUSE'S NAME
7. CHILD'S NAME
(mm/dd/yyyy)
2. SPOUSE'S SOCIAL SECURITY NUMBER
9. CHILD'S SOCIAL SECURITY NUMBER
8. CHILD'S DATE OF BIRTH
(mm/dd/yyyy)
(mm/dd/yyyy)
3. SPOUSE'S DATE OF BIRTH
10. DATE CHILD BECAME YOUR DEPENDENT
(Check one)
4. SPOUSE'S SELF-IDENTIFIED GENDER IDENTITY
11. CHILD'S RELATIONSHIP TO YOU
MALE
FEMALE
SON
DAUGHTER
STEPSON
STEPDAUGHTER
(mm/dd/yyyy)
12. WAS CHILD PERMANENTLY AND TOTALLY DISABLED BEFORE THE AGE OF 18?
5. DATE OF MARRIAGE
YES
NO
6. SPOUSE'S ADDRESS AND TELEPHONE NUMBER
13. IF CHILD IS BETWEEN 18 AND 23 YEARS OF AGE, DID CHILD ATTEND
(Street, City, State, ZIP - if different from Veteran's)
SCHOOL LAST CALENDAR YEAR?
YES
NO
14. EXPENSES PAID BY YOU FOR YOUR DEPENDENT CHILD FOR COLLEGE,
(e.g., tuition, books, materials)
VOCATIONAL REHABILITATION OR TRAINING
15. IF YOUR SPOUSE OR DEPENDENT CHILD DID NOT LIVE WITH YOU LAST YEAR, DID YOU PROVIDE SUPPORT?
YES
NO
REMEMBER TO SIGN AND DATE THE FORM ON THE REVERSE PAGE
PREVIOUS EDITIONS OF THIS FORM ARE NOT TO BE USED
VA FORM
10-10EZR
PAGE 1
APR 2017
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