Va Form 10-10ezr - Health Benefits Update Form Page 3
Download a blank fillable Va Form 10-10ezr - Health Benefits Update Form in PDF format just by clicking the "DOWNLOAD PDF" button.
Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.
Complete Va Form 10-10ezr - Health Benefits Update Form with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.
Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.
ADVERTISEMENT
1
2
3
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).
1. VETERAN'S NAME (Last, First, Middle Name)
2. SOCIAL SECURITY NUMBER
3. GENDER
4. DATE OF BIRTH (mm/dd/yyyy)
5. HOME TELEPHONE NUMBER (Include area code)
6. MOBILE TELEPHONE NUMBER (Include area code)
MALE
FEMALE
7. PERMANENT ADDRESS (Street)
8. CITY
9. STATE
10. ZIP CODE
11. COUNTY
12. E-MAIL ADDRESS
13. CURRENT MARITAL STATUS
MARRIED
NEVER MARRIED
SEPARATED
WIDOWED
DIVORCED
SECTION II - INSURANCE INFORMATION (Use a separate sheet for additional information)
1. ENTER YOUR HEALTH INSURANCE COMPANY NAME, ADDRESS AND TELEPHONE NUMBER (include coverage through spouse or other person)
2. NAME OF POLICY HOLDER
3. POLICY NUMBER
4. GROUP CODE
5. ARE YOU ELIGIBLE
FOR MEDICAID?
YES
NO
6. ARE YOU ENROLLED IN MEDICARE HOSPITAL
7. EFFECTIVE DATE (mm/dd/yyyy)
YES
NO
INSURANCE PART A?
SECTION III - DEPENDENT INFORMATION (Use a separate sheet for additional dependents)
1. SPOUSE'S NAME (Last, First, Middle Name)
6. CHILD'S NAME (Last, First, Middle Name)
2. SPOUSE'S SOCIAL SECURITY NUMBER
7. CHILD'S DATE OF BIRTH (mm/dd/yyyy)
8. CHILD'S SOCIAL SECURITY NUMBER
3. SPOUSE'S DATE OF BIRTH (mm/dd/yyyy)
9. DATE CHILD BECAME YOUR DEPENDENT (mm/dd/yyyy)
4. DATE OF MARRIAGE (mm/dd/yyyy)
10. CHILD'S RELATIONSHIP TO YOU (Check one)
SON
DAUGHTER
STEPSON
STEPDAUGHTER
11. WAS CHILD PERMANENTLY AND TOTALLY DISABLED BEFORE THE AGE OF 18?
5. SPOUSE'S ADDRESS AND TELEPHONE NUMBER
(Street, City, State, ZIP - if different from Veteran's)
YES
NO
12. IF CHILD IS BETWEEN 18 AND 23 YEARS OF AGE, DID CHILD ATTEND
SCHOOL LAST CALENDAR YEAR?
YES
NO
13. EXPENSES PAID BY YOU FOR YOUR DEPENDENT CHILD FOR COLLEGE,
VOCATIONAL REHABILITATION OR TRAINING (e.g., tuition, books, materials)
14. IF YOUR SPOUSE OR DEPENDENT CHILD DID NOT LIVE WITH YOU LAST
YES
NO
YEAR, DID YOU PROVIDE SUPPORT?
REMEMBER TO SIGN AND DATE THE FORM ON THE REVERSE PAGE
PAGE 1
10-10EZR
PREVIOUS EDITIONS OF THIS FORM ARE NOT TO BE USED
VA FORM
MAR 2015
ADVERTISEMENT
0 votes
Related Articles
Related forms
Va Form 10-0094h - Education Affiliation Agreement Between The Department Of Veterans Affairs (va) And A Non-va Health Care Facility Or Agency
Legal
Va Form 10-0485 - Request For And Authorization To Release Protected Health Information To Nationwide Health Information Network
Legal
Related Categories
Parent category: Legal