Information Collection

Application and Renewal for Health Benefits

IC 28251 under ICR 200703-2900-020 · OMB 2900-0091.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 2900-0091 can be found here:

Documents and Forms

Document Name Document Type
Form 10-10EZ Application and Renewal for Health Benefits Form
10-10EZ Application for Health Care Benefits 2900-0091 VA Form 10-10ez.pdf www.va.gov/healtheligibility/application/ Form
10-10EZR HEALTH BENEFITS RENEWAL FORM 2900-0091 VA Form 10-10ezr-fill.pdf www.va.gov/vaforms Form

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Application and Renewal for Health Benefits	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	10-10EZ	Application for Health Care Benefits	2900-0091 VA Form 10-10ez.pdf	http://www.va.gov/healtheligibility/application/	Yes	Yes	Fillable Fileable
Form	10-10EZR	HEALTH BENEFITS RENEWAL FORM	2900-0091 VA Form 10-10ezr-fill.pdf	http://www.va.gov/vaforms	Yes	No	Fillable Printable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 1,904,940	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 3 %

	Approved	Program Change Due to Agency Discretion	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	1,904,940	4,940	0	1,900,000
Annual IC Time Burden (Hours)	1,008,180	0	3,180	1,005,000
Annual IC Cost Burden (Dollars)	0	0	0	0

Documents for IC

Title	Document	Date Uploaded
No associated records found

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.