VA Form 10-10EZ — Application for Health Benefits
VA health-care enrollment packet (VA Form 10-10EZ) for eligible veterans
- 1Fill it out
- 2Review
- 3Sign
- 4Download
About you
VA requires an SSN on the final form. Default: leave blank here and write it on the printed packet before your VA visit — zero data crosses our boundary. Tap 'Enter digitally' below only if you want a fully-completed PDF; values are encrypted on our servers and auto-deleted after 30 days.
If you're escaping abuse or unsafe at your current address, ask the partner where you'll submit this form whether you can use a safe-address (FJC, library, or partner agency). We won't track which address you used.
How we handle addresses →Service history
Post-9/11 combat service unlocks a 5-year enhanced enrollment window.
Income + insurance (priority group)
VA uses income and insurance status to assign you to a priority group (1-8). Priority 1 (service-connected 50%+) has fewest copays.
Why you're enrolling now
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