Va Form 10-10ezr - Heath Benefits Update Form - Department Of Veterans Affairs Page 4

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(Last, First, Middle)

VETERAN'S NAME

SOCIAL SECURITY NUMBER

HEALTH BENEFITS UPDATE FORM

SECTION IV - PREVIOUS CALENDAR YEAR GROSS ANNUAL INCOME OF VETERAN, SPOUSE AND DEPENDENT CHILDREN

(Use a separate sheet for additional dependents)

VETERAN

SPOUSE

CHILD 1

(wages, bonuses, tips,

1. GROSS ANNUAL INCOME FROM EMPLOYMENT

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 V - 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 III.)

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.

SECTION VI - CONSENT TO COPAYS AND TO RECEIVE COMMUNICATIONS

By submitting this application you are agreeing to pay the applicable VA copays for treatment or services of your NSC conditions as required by law. You also

agree to receive communications from VA to your supplied email or mobile number.

ASSIGNMENT OF BENEFITS

I understand that pursuant to 38 U.S.C. Section 1729 and 42 U.S.C. 2651, the Department of Veterans Affairs (VA) is authorized to recover or collect from my health plan

(HP) or any other legally responsible third party for the reasonable charges of nonservice-connected VA medical care or services furnished or provided to me. I hereby

authorize payment directly to VA from any HP under which I am covered (including coverage provided under my spouse's HP) that is responsible for payment of the

charges for my medical care, including benefits otherwise payable to me or my spouse. Furthermore, I hereby assign to the VA any claim I may have against any person or

entity who is or may be legally responsible for the payment of the cost of medical services provided to me by the VA. I understand that this assignment shall not limit or

prejudice my right to recover for my own benefit any amount in excess of the cost of medical services provided to me by the VA or any other amount to which I may be

entitled. I hereby appoint the Attorney General of the United States and the Secretary of Veterans' Affairs and their designees as my Attorneys-in-fact to take all necessary

and appropriate actions in order to recover and receive all or part of the amount herein assigned. I hereby authorize the VA to disclose, to my attorney and to any third party

or administrative agency who may be responsible for payment of the cost of medical services provided to me, information from my medical records as necessary to verify

my claim. Further, I hereby authorize any such third party or administrative agency to disclose to the VA any information regarding my claim.

SECTION VII - SUBMITTING YOUR UPDATE

ALL APPLICANTS MUST SIGN AND DATE THIS FORM. REFER TO INSTRUCTIONS WHICH DEFINE WHO CAN SIGN ON BEHALF OF THE

VETERAN.

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).

l declare under penalty of perjury that the foregoing is true and accurate to the best of my knowledge. I understand that any materially false, fictitious, or fraudulent

statement or representation, made knowingly, is punishable by a fine and/or imprisonment pursuant to title 18, United States Code, Sections 287 and 1001.

SIGNATURE OF APPLICANT:

(Sign in ink)

DATE:

VA FORM

10-10EZR

PAGE 2

APR 2017