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10 10EZ PDF

Fill out an Application for Health Benefits (VA Form EZ). Download VA Form EZ. You or someone acting as your power of attorney. Which sections of VA Form EZ should you complete? Definitions of terms used on this form. If you desire a health care appointment, contact the Enrollment . Complete and submit the VA Form EZ to apply for enrollment in the VA health care system.

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Typically, veterans who have NOT previously enrolled or applied for VA health care benefits should use this form. Before beginning the online submission process, we suggest viewing or printing the EZ to assist you in gathering all the information required to complete it. This is a “smart” form in that it will route you around sections of the form you do not have to complete which is based on the information you enter. To navigate this form, use the buttons provided on each page.

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Do not use the browser ” Back ” and ” Forward ” buttons. Because of the sensitive nature of the information requested, the information is not saved in your computer or on our web server.

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Therefore, the form must be completed in a single session. Additionally, 10rz online form limits the amount of time your browser can remain idle.

VA Form EZ – Application for Medical Benefits (Enroll) (Health Eligibility Center)

If you stay on a single page for more than 20 minutes, 10rz window will be displayed asking if you want to continue or close the online form. Click the “Continue” button promptly to avoid closing your form and erasing the information you have entered. You will be provided an opportunity to review and change your information prior to submission.

You the applicant must sign and date the printed copy and mail or fax it to the selected VA Facility. If you have delegated someone else to sign 1 form, we must receive a copy of the Power of Attorney.

If you the applicant are unable to sign the form, two people known to the applicant may witness the applicant making an “X” on the form.

The witnesses must also sign the form and print their names. If the form is not signed and dated, VA will return it to the applicant to complete. This will result in a delay in processing the application. We will begin processing the application upon receipt of the signed form. 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.

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Click this link to run a Printing Test to ensure that 10es 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 01ez see the words “Print 10fz successful”you should check to make sure that Acrobat Reader has been installed.

I have read this page and 10e to go to the Online Submission Form. If your browser does not have scripting enabled, or it does not support it.

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Instructions for Completing VA Form EZ On-Line Before beginning the online submission process, we suggest viewing or printing the EZ to assist you in gathering all the information required to complete it. You must have the latest version of Adobe Acrobat Reader on your computer to save or print the forms.

Click here to obtain a free copy of the Adobe Acrobat Reader software.