Information Collection

Application and Renewal for Health Benefits

IC 28251 under ICR 200812-2900-018 · 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⚠️ Notice: This information collection may be referencing outdated material.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
VA Form 10-10EZR Health Benefits Renewal Form 10-10ezr-fill-JUL08 copy.pdf www.va.gov/vaforms Form
10-10EZ Application for Health Benefits 10-10ez.pdf www.va.gov/healtheligibility/application/ Form
VA Form 10-10HS Request for Hardship Determination VA Form 10-10HS (5) (5).pdf Form and Instruction

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: 38 CFR 70.20 38 CFR 70.31(e) 38 CFR 70.31(c)

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 Benefits	10-10ez.pdf	http://www.va.gov/healtheligibility/application/	Yes	Yes	Fillable Fileable
Form and Instruction	VA Form 10-10HS	Request for Hardship Determination	VA Form 10-10HS (5) (5).pdf	TBD	Yes	No	Fillable Printable
Form	VA Form 10-10EZR	Health Benefits Renewal Form	10-10ezr-fill-JUL08 copy.pdf	http://www.va.gov/vaforms	Yes	No	Fillable Printable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title: 24VA19 Patient Medical Record - VA	FR Citation: 72 FR 15

Number of Respondents: 2,075,312	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	Previously Approved
Annual Number of Responses for this IC	2,075,312	3,500	2,071,812
Annual IC Time Burden (Hours)	1,114,740	875	1,113,865
Annual IC Cost Burden (Dollars)	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.