10 10EZR PDF

What is VA Form EZR used for? Ask VA to help you fill out the form by calling us at VETS (). Access our website at and. Fill va form 10 10ezr va instantly, download blank or editable online. Sign, fax and printable from PC, iPad, tablet or mobile. No software. Try Now!. Form, VA Form EZR, Health Benefits Renewal Form ยท ezr-fill-JUL08 , , Yes, No, Fillable Printable. Form and.

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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.

10esr navigate this form, use the buttons provided on each page. 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. Therefore, the form must be completed in a single session. Additionally, the online form limits the amount of time your browser can remain idle. If 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 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 the 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. 10ezd

VA Form 10-10EZ – Application for Medical Benefits (Enroll)

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. Click this link to run a Printing Test 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. I have read this page and want to go to the Online Submission Form. If your browser does not have scripting enabled, or it does not support it.

The forms may not function correctly. Enter your search text Button to start search.

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

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 10szr 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.