Information Collection

Application and Renewal for Health Benefits

IC 28251 under ICR 201306-2900-006 · 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⚠️ Notice: This information collection may be referencing outdated material.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 VA form 10-10EZ Application and Renewal for Health Benefits Form
VA form 10-10EZ Application for Health Benefits VHA-1010EZ-new-fill V2v1_07302013.pdf www.va.gov/healtheligibility/application/ Form
VA Form 10-10HS Request for Hardship Determination 10-10HS-fill.pdf www.va.gov/vaforms/medical/pdf/vha-10-10HS.pdf Form and Instruction
VA Form 10-10EZR Health Benefits Renewal Form VHA-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: 38 CFR 70.20 38 CFR 70.31(c) 38 CFR 70.31(e)

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	VA form 10-10EZ	Application for Health Benefits	VHA-1010EZ-new-fill V2v1_07302013.pdf	http://www.va.gov/healtheligibility/application/	Yes	Yes	Fillable Fileable
Form and Instruction	VA Form 10-10HS	Request for Hardship Determination	10-10HS-fill.pdf	http://www.va.gov/vaforms/medical/pdf/vha-10-10HS.pdf	Yes	No	Fillable Printable
Form	VA Form 10-10EZR	Health Benefits Renewal Form	VHA-10-10EZR-fill.pdf	http://www.va.gov/vaforms	Yes	Yes	Fillable Fileable

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: 1,017,000	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	1,017,000	-1,058,312	2,075,312
Annual IC Time Burden (Hours)	455,750	-658,990	1,114,740
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.