VA Health Benefits: Application, Update, Hardship Determination - VA Forms 10-10EZ,10-10EZR, 10-10HS
No material or nonsubstantive change to a currently approved collection
No
Regular
04/30/2026
Requested
Previously Approved
07/31/2027
07/31/2027
1,406,000
1,406,000
703,300
703,300
0
0
Title 38 U.S.C. Chapter 17 authorizes VA to provide hospital care, medical services, domiciliary care, and nursing home care to eligible Veterans. Title 38 U.S.C. § 1705 requires VA to design, establish, and operate a system of annual patient enrollment in accordance with a series of stipulated priorities. Title 38 U.S.C. § 1722 establishes eligibility assessment procedures for cost-free VA medical care, based on income levels, which determines whether nonservice-connected and 0% service-connected non-compensable Veterans are able to defray the necessary expenses of care for nonservice-connected conditions. Further, when the Veteran projects that his or her attributable income for the current calendar year would be substantially below the applicable income thresholds, the Veteran would be considered unable to defray the expenses of care and VA may exempt the Veteran from the requirement to pay copayments for hospital or outpatient care. In addition, Section 103 of Public Law 117-168, titled the Sergeant First Class Heath Robinson Honoring our Promise to Address Comprehensive Toxics (PACT) Act of 2022, amended Title 38 U.S.C. Section 1710(e) (3), by expanding the health care eligibility benefit for Veterans who participated in a toxic exposure risk activity (TERA) while serving on active duty, active duty for training, or inactive duty training.
This collection of information is required to properly administer health benefits to eligible Veterans:
a. VA Form 10-10EZ, Application for Health Benefits, is used to collect Veteran information during the initial application process for VA medical care, nursing home, domiciliary, dental benefits, etc.
b. VA Form 10-10EZR, Health Benefits Update Form, is used to update a Veteranâs personal information, such as marital status, address, health insurance and financial information, for renewal of health benefits.
c. VA Form 10-10HS, Request for Hardship Determination, is used to collect information from Veterans who are in a copay required status for hospital care and medical services, but due to a loss of income project their income for the current year will be substantially below the VA means test limits.
These forms collect information to enroll a Veteran for health benefits, establish basic eligibility, determine TERA benefit eligibility, identify 3rd party health insurance coverage, identify prescription copayment, provide for income verification, and serve as a mechanism to make changes upon admission for benefits or yearly financial updates.
VA Form 10-10EZR has been updated to match the Race/Ethnicity field in VA Form 10-10EZ, which will allow applicants to make any necessary changes to this information. There are no changes to the respondent or burden numbers as a result of this update.
PL:
Pub.L. 117 - 168 103
Name of Law: Sergeant First Class Heath Robinson Honoring our Promise to Address Comprehensive Toxics (PACT) Act
US Code:
38 USC Chapter 17
Name of Law: HOSPITAL, NURSING HOME, DOMICILIARY,
PL: Pub.L. 115 - 182 101 Name of Law: MISSION Act of 2018
On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).
The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:
(i) Why the information is being collected;
(ii) Use of information;
(iii) Burden estimate;
(iv) Nature of response (voluntary, required for a benefit, or mandatory);
(v) Nature and extent of confidentiality; and
(vi) Need to display currently valid OMB control number;
If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.
VA Form 10-10EZR