VA Form 10-10EZ applies for VA health care. Your service-connected disability rating can affect your enrollment priority and costs, but health care enrollment and disability compensation are separate processes. Veterans without an existing disability rating may qualify through other eligibility rules.

Download the current VA Form 10-10EZ PDF

Download the official February 2025 PDF from VA's form page. I verified the six-page edition on October 2, 2026. Pages 1 through 3 contain instructions; the application occupies pages 4 through 6.

VA also offers an online health care application. On paper, item numbers restart within sections. “Item 1” alone is therefore not a useful reference without its section.

Who files it, and which sections apply?

Veterans seeking enrollment use this application. If you are already enrolled and need to update personal, financial, insurance or military-service information, VA directs you to 10-10EZR, the Health Benefits Update Form.

The top of Section I distinguishes Enrollment, for the medical benefits package, from Registration, for specified treatment authorities that do not require enrollment. Page 1 explains those authorities. Choose the purpose that applies; do not treat the two boxes as interchangeable.

The instructions say all veterans must complete Sections I through III. Later sections apply according to your circumstances and financial-disclosure choices. Read the exemption list before assuming every applicant must report household income.

Gather your separation papers, insurance information and relevant household records. VA's application instructions explain that financial information is not always necessary, but VA may need it to establish eligibility when you lack another qualifying basis.

How your disability rating affects priority groups

VA assigns enrolled veterans to one of eight priority groups. If you qualify for several, it assigns the highest one. Service-connected means VA has determined that a disability is related to military service.

  • Priority group 1: A service-connected rating of 50% or more, VA's finding of unemployability due to service-connected disability, or a Medal of Honor.
  • Priority group 2: A service-connected rating of 30% or 40%.
  • Priority group 3: A service-connected rating of 10% or 20%. Other qualifying circumstances include a Purple Heart, former prisoner-of-war status and certain disability discharges.
  • A 0% rating: It does not automatically mean group 1, 2 or 3. A noncompensable 0% rating combined with qualifying income may fit group 5; VA lists a compensable 0% rating under group 6. Other eligibility factors can change the result.

Income, Medicaid, pension, catastrophic disability, combat service and toxic-exposure history may also matter. Veterans without a disability rating should still review the eligibility rules.

The priority group affects costs, but do not interpret every rating as making every service free. VA's cost-of-care explanation distinguishes care for service-connected conditions from other care and explains how eligibility factors affect copays.

If you are unsure how several ratings combine, Claim Raven's public calculator estimates the combined rating and compensation from your inputs without an account. Use your actual award when answering VA's application; a hypothetical calculator result is not an awarded rating.

Section I: general information, Items 1A through 16

Complete the benefit-type selection, then work through the identification fields:

  • 1A and 1B: Legal name and preferred name.
  • 2: Mother's maiden name.
  • 3: Sex, using the printed selections.
  • 4: Race and ethnicity; check applicable selections. The form includes an option to decline to answer and says this information is for statistics.
  • 5: Social Security number.
  • 6A and 6B: Date and place of birth.
  • 7 and 8: Preferred language and religion.
  • 9A through 9E: Mailing address, city, state, ZIP code and county.
  • 9F through 9H: Home phone, mobile phone and email, each marked optional.
  • 10A through 10E: Home address, city, state, ZIP code and county.
  • 11: Current marital status.
  • 12A through 12D: Next of kin's name, address, relationship and phone.
  • 13A and 13B: Emergency contact's name and phone.
  • 14: The person designated to receive personal property left on VA-controlled premises after departure or death. The form says this does not create a will or transfer title.
  • 15: Your preferred VA medical center or outpatient clinic.
  • 16: Whether you want VA to contact you to schedule the first appointment.

Mailing and home addresses are separate fields. Make sure VA can reach you and that the facility in Item 15 is the one you intend to use.

Section II: military service and exposures

1A through 1F request the last branch of service, last entry date, future discharge date where applicable, last discharge date, discharge type and military service number. Copy from your records rather than approximating a discharge characterization.

2A through 2F ask Yes or No about:

  • Purple Heart receipt.
  • Former prisoner-of-war status.
  • Combat-theater service after November 11, 1998.
  • Discharge or retirement for a disability incurred in the line of duty.
  • Southwest Asia service during the specified August 2, 1990, through November 11, 1998, period.
  • Whether you have a VA service-connected rating.

2F is a Yes/No question, not a blank for a percentage. Answer based on VA's existing determination.

The section continues on page 5 with exposure questions 3A through 3E:

  • 3A: Specified radiation locations and nuclear testing, treatment or cleanup activities.
  • 3B: Listed Gulf War hazard locations and approximate service dates.
  • 3C: Deployment in support of the named operations.
  • 3D: Listed herbicide locations or activities and approximate service dates.
  • 3E: Exposure categories such as air pollutants, chemicals, Camp Lejeune water, radiation, occupational hazards and warfare agents, with approximate dates.

Read the actual location lists on the PDF. They are more detailed than a single “burn pits” question. When you report an exposure, page 1 permits a written statement or witness statements. Answer from your service history; the health care application does not itself award disability compensation for an exposure.

Section III: insurance, Items 1 through 6C

Item 1 asks for the health insurer's name, address and phone, including coverage through a spouse or another person. 2 asks for the policyholder, 3 the policy number, and 4 the group code. Use a separate sheet for additional information.

Item 5 asks about Medicaid eligibility. 6A asks whether you are enrolled in Medicare hospital insurance, Part A; 6B asks its effective date; 6C asks the Medicare number.

Report the insurance you actually have. Do not leave an employer policy out merely because you are applying for VA care. The instructions also tell you to bring insurance, Medicare and Medicaid cards to health care appointments.

Section IV: dependent information

For a spouse, Item 1 and 1A through 1E request name, Social Security number, birth date, sex, marriage date, and address and phone if different from yours.

For a child, Item 2 and 2A through 2G request name, birth date, Social Security number, date the child became your dependent, relationship, whether the child was permanently and totally disabled before 18, school attendance last year for ages 18 through 23, and qualifying education expenses paid by a child with reportable income.

Item 3 asks whether you provided support last year when your spouse or dependent child did not live with you. The instructions explain which dependents to include and permit another sheet for additional children.

These entries support the health care application. They do not replace adding dependents for compensation through VA Form 21-686c, and they do not enroll a spouse or child in CHAMPVA.

Sections V and VI: work and financial disclosure

In Section V, 1A asks whether you work full time, part time, are not employed, or are retired. 1B requests the retirement date where applicable. 1C through 1E ask for company name, address and telephone when employed or retired.

Section VI has unnumbered Yes/No financial-disclosure choices. Select Yes to provide the applicable household information in Sections VII and VIII, or No to decline and proceed to the signature as directed.

Page 2 lists circumstances in which financial disclosure is not required, including receipt of service-connected disability compensation, VA pension, Medicaid, and specified service or exposure histories. Declining can nevertheless affect eligibility for income-based benefits, such as cost-free medication or travel assistance. If income is needed to establish your enrollment eligibility, withholding it can prevent enrollment.

Sections VII and VIII: last year's income and expenses

Section VII separates amounts for the veteran, spouse and child:

  • Item 1: Gross employment income, excluding farm, ranch, property or business income.
  • Item 2: Net income from those farm, ranch, property or business sources.
  • Item 3: Other income under the instructions, including applicable retirement, Social Security, compensation, interest and dividends.

Use the previous calendar year. An application completed in 2026 asks for 2025 information. Read the page 2 exclusions, which include items such as Supplemental Security Income, specified need-based payments and school scholarships. Do not assume every deposit is reportable income or that every benefit is excluded.

Section VIII asks for:

  • Item 1: Unreimbursed medical expenses paid by you or your spouse. Do not include amounts you expect insurance or another source to reimburse.
  • Item 2: Qualifying funeral and burial expenses, including prepaid burial expenses, paid last year for a deceased spouse or dependent child.
  • Item 3: Your own college or vocational education expenses. Dependent-child education expenses belong in the earlier dependent section.

Keep gross wages, net business income and deductible expenses in their proper fields. The instructions say VA calculates the applicable medical-expense deduction.

Section IX and the signature

Section IX explains consent to applicable copays and communications. Read the separate Assignment of Benefits language below it, which addresses VA's recovery of certain costs from health plans or responsible third parties.

Sign in ink and date the paper application. If someone acts under your power of attorney, attach the authority document. If you sign with an X, two witnesses must sign and print their names. VA's instructions say an improperly signed or dated form will be returned for completion.

Fictional example: a veteran with a 40% rating

This is a fictional worksheet exercise, not a real veteran or enrollment outcome. Personal identifiers and financial amounts are omitted.

Assume a veteran has an awarded 40% service-connected rating, employer insurance and no other basis for a higher priority group.

  • Section I selects enrollment, identifies the veteran and requests first-appointment contact in Item 16.
  • Section II, 2F is Yes because VA has already awarded service connection.
  • Section III reports the employer policy, including its policyholder and identifiers.
  • Applicable household and employment sections use the veteran's actual records.
  • The veteran reviews the financial-disclosure exemptions before choosing whether to provide income.
  • The veteran signs and dates the completed application.

Under VA's published rating criteria, 40% fits priority group 2 in this example. VA makes the actual assignment after reviewing all qualifying factors. The application does not turn the 40% award into a higher compensation rating.

Where to submit it, and what happens next

VA's current application guidance provides these options:

  • Online: Use VA's health care application.
  • Mail: Health Eligibility Center, PO Box 5207, Janesville, WI 53547-5207.
  • Phone: Call 877-222-8387, Monday through Friday, 8 a.m. to 8 p.m. Eastern.
  • In person: Bring the signed form to a VA medical center or clinic.

Fax: Neither the current PDF nor VA's national application page provides a general enrollment fax number. Local facilities may have their own instructions. Confirm with the receiving facility before using a local number; do not substitute a compensation-claims fax.

Keep the signed application and receipt. VA's after-application page says it will mail a decision and, after approval, provide a welcome call and health benefits handbook. The handbook explains the assigned priority group and copays. If more than a week passes without contact, VA says to call the enrollment line rather than apply again.

Check both addresses, service and exposure answers, insurance details, the income year, and the signature. Use 10-10EZR for later updates. VA may require 10-10EC for certain extended-care services; its application guidance explains that separate form. For appointed representation, see the 21-22 and 21-22a walkthrough.

Verified October 2, 2026: all six pages of the February 2025 PDF, official form page, national application instructions, priority-group guidance and after-application guidance. No national fax destination was verified. The example does not promise enrollment, a particular copay or a new disability rating.

Where to go next

Claim Raven is data analysis, not legal, medical, or VA-accredited advice. VA's enrollment staff can answer questions about your eligibility, priority group and application.

-Landon Founder, Claim Raven | U.S. Army Veteran