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Signature Needed
Submission Process
Privacy and Security
Cookies
System Requirements
Printable Form
Enrollment Alternatives
For your convenience, we are providing this online VA Form 10-10EZ, "Application for Health Benefits." Submission of this application will provide us with the information that we need to begin the enrollment application process for you. By completing this application online, you can submit the form electronically to your VA health care facility of choice to expedite your enrollment.
Important: Before beginning the online submission process, it is suggested that you view
or print a copy of the form, then gather all the information required to complete the whole
form. Because of the sensitive nature of the information requested, the information is not saved in your computer or on our web server and cannot be retrieved to be finished at another time.
Therefore, the form must be completed in a single session. Additionally, the online application limits the amount of time your browser can remain idle.
If for any reason you stay on a single page for more than 20 minutes,
a window will be displayed asking if you want to continue or close the
application. Please click the Continue button promptly to avoid closing
your form and erasing all the information you have entered. Also, do not use the browser "Back" and "Forward" buttons.
To navigate this form, use the buttons provided on each page.
You will be provided an opportunity to review and change your information
prior to submission.
This is a smart form that will route you around sections
you do not have to complete based on information that you have entered. If, at any time, you wish to discontinue the submission process, be sure to close your browser to ensure
that any data entered is no longer viewable on your computer. All information is erased on your computer, as well as on the
VA Server, whenever your browser is closed. |
Signature Needed
This form requires a signature, and you will have to send us a signed copy before
we can complete your enrollment. You or an individual to whom you have delegated your Power of Attorney must sign and date the form. If you sign with an "X", then you must have two people you know witness you as you sign. They must then sign the form and print their names. If the form is not signed and dated appropriately, VA will return it for you to complete. This will result in a delay in VA's processing your application. After you have finished online data entry and reviewed
your submission, you will have two choices:
(a) Fastest - Print the form and electronically submit it. Sign the printed
copy and mail or fax it to the address provided when you submit the form. We begin processing the
electronically submitted application immediately upon receipt of your signed form.
Printing requires Acrobat Reader.
If you don't have Acrobat, download it here then run the printing test below to check your installation. If you have a pop-up blocker on your computer, you should adjust it to allow a pop-up from this site or disable it while completing this form. Click the link below to quickly test your system to ensure that you will be able to print your completed form. If a new window does not appear, please check for a pop-up blocker. If you do not see the words "Print test successful", you should check to make sure that Acrobat Reader has been installed.
Of course, you can continue to use the paper form and mail service. No one
is required to use the online submission process. We are adding this online process as an
added convenience for those who choose to use it.
(b) Fast - If you cannot print, sign, and mail the form, or choose not to, we will mail
you a printed copy of your information that you can sign and return to us. The added
time taken for us to process our mailing to you and mail transit time will lengthen
the enrollment process.
Submission Process
The first page contains the general instructions for completing the application. By selecting your veteran status, you will be presented only the sections that need to be completed. Each web page you will see is designed to look similar to the printed form, but will not be exact. You must provide all the required information. Your information entries will be tested for valid format and missing field entries. These checks will be performed prior to moving to the next form page.
At the end of the form, you will be given the option to provide some information not requested on the printed form. This information will help us process your form and provide you with needed services.
Privacy and Security
The VA realizes that the information requested is sensitive, and that many people have concerns about submitting this kind of information over the Internet. Therefore, the VA is making every effort to ensure the confidentiality and privacy of your protected health information by using the current best security measures.
In addition to our normal security measures, (see Privacy & Security Statement), additional measures are taken for applications that involve private information about you as an individual.
From your computer to the VA, the information will be protected using Secure Sockets Layer (SSL) encryption. This is automatically handled by most browsers, and is widely accepted as adequate protection for the transmission of information on the Internet. When the information is received at the VA, it is immediately moved behind a "firewall" into the protected internal VA environment. Your information does not stay on our Internet servers. Our firewalls and servers are regularly updated and monitored to further protect the systems from inappropriate access.
Important Note:
If you print your completed 10-10EZ form, a copy of the PDF form may be saved on your computer. This file would contain your personal information. After you complete the form, you may want to clear your browser's cache to ensure your privacy, especially if you are using a computer that other people can access. Instructions will be provided after you submit your online form.
Cookies
To process all the information, the online Form10-10EZ uses temporary session cookies. "Cookies" are pieces of information that are stored locally on your system. Some cookies are stored in a file on your hard drive, and can remain there for a long time. This form does not use that kind of cookie. The information stored on your system is a temporary session cookie that does not contain any personal information, but provides the ability for you to verify and edit your information. As soon as the form is submitted and the information has been forwarded to the VA Medical Center of your choice, the temporary session cookie and all the information on the server are erased. It is also erased whenever the connection is lost for any reason.
System Requirements
These pages require either Internet Explorer 3.02 or Netscape Navigator 3.0, or later versions. Best viewing will be obtained with a display resolution of 800 X 600 or higher (640 X 480 will work, but considerable scrolling will be needed).
View or Print Form 10-10EZ
To print a copy of the blank Form 10-10EZ to assist you in collecting the required information, or if you do not wish to submit your enrollment form online, you may view or print the form, using the the latest version of Adobe Acrobat Reader.
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Click here to obtain a free copy of the Adobe Acrobat software. |
Enrollment Alternatives
There are several other ways to enroll:
You can enroll in person at any VA Medical Center or Clinic.
You can obtain enrollment assistance by calling VA's Health Benefits Service Center, Monday through Friday between the hours of 8:00 AM and 8:00 PM (Eastern Time) at 1-877-222-VETS.
You can also enroll by mailing or faxing the completed Form10-10EZ to the Medical Center or Clinic of your choice. See VHA Facilities Locator
You can also obtain additional assistance by contacting your State or County Veterans Service Officer. For telephone listings please consult the blue pages of your local phone book under "United States Offices", then look for "Veterans Affairs" or check our VSO Listing.
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For inquiries about health care, please click here: Contact the VA
This page was last updated September 22, 2004