Acceda al sitio web de VA a y seleccione Contáctese con VA (” Contact the VA”). ¿Para qué sirve el Formulario VA EZ? AFECCIÓN. Fill va form 10 10ez va instantly, download blank or editable online. Sign, fax and printable from PC, iPad, tablet or mobile. No software. Try Now!. VA Form EZ – Application for Medical Benefits (Enroll). The primary purpose of this form is to request enrollment in the VA Health Care.

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If you stay on a single page for more than 20 minutes, a window will be displayed asking 1010eez you want to continue or close the online form. Additionally, the online form limits the amount of time your browser can remain idle.

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Click this link to run a Printing Test to ensure that you will be able to print your completed form. If the form is not signed and dated, VA will return it to the applicant to complete. You must have the latest version of Adobe Acrobat Reader on your computer to save or print the forms.

We will begin processing the application upon receipt of the signed form. This will result in a delay in processing the application. The forms may not function correctly.


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

You will be provided an opportunity to review and change your information prior to submission. If you have delegated someone foorm to sign the form, we must receive a copy of the Power of Attorney.

If your browser does not have scripting enabled, or it does not support it. The witnesses must also sign the form and print their names. Therefore, the form must be completed in a single session.

To navigate this form, use the buttons provided on each page. Because of the sensitive nature of the information requested, the information is not saved in your computer or on our web server. If you do not see the words “Print test successful”you should check to make sure that Acrobat Reader has been installed.

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

Enter your search text Button to start search. I have read this page and want to go to the Online Submission Form. 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.

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 gathering all the information required to complete it. Do not use the browser ” Back ” and ” Forward ” buttons. 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.


Click the “Continue” button promptly to avoid closing your form and erasing the information you have entered. Click here to obtain a free copy of the Adobe Acrobat Reader software. Typically, veterans who have NOT previously enrolled or applied for VA health care benefits should use this form. corm

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. If a new window does not appear, please check for a pop-up blocker.

You the applicant must sign and date the printed copy and mail or fax it fkrm the selected VA Facility. 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.