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.

Author: Faushura Dojind
Country: Kenya
Language: English (Spanish)
Genre: Medical
Published (Last): 4 July 2005
Pages: 179
PDF File Size: 19.61 Mb
ePub File Size: 7.89 Mb
ISBN: 613-7-67702-393-8
Downloads: 57552
Price: Free* [*Free Regsitration Required]
Uploader: Mezisar

Click here to obtain a free copy of the Adobe Acrobat Reader software.

VA Health Benefits Application Form (EZ) – VFW Post

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. Rorm the “Continue” button promptly to avoid closing your form and erasing the information you have entered.

If a new window does not appear, please check for a pop-up blocker. 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 forrm to the applicant may frm the applicant making an “X” on the form. You must have the latest version of Adobe Acrobat Reader on your computer to save or print the forms. If you do not see the words “Print test successful”you should check to make sure that Acrobat Reader has been installed.

  6AV6 643 0AA01 1AX0 PDF

Additionally, the online form limits the amount of time your browser can remain idle. If you have delegated someone else to sign the form, we must ca a copy of the Power of Attorney. If the form is not signed and dated, VA will return it to the applicant to complete.

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 you stay on a single page for more than 20 minutes, a window will be displayed asking if you want to continue or close the online form. Do not use the browser ” Back ” and ” Forward ” buttons. The forms may not function correctly. Enter your search text Button to start search.

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

This is a “smart” form in that it will route you around sections of the form you do not have to complete 1010ea is based on the information you enter.

To navigate this form, use the buttons provided on each page. This will result in a delay in processing the application. You the applicant must dorm and date the printed copy and mail or fax it to the selected VA Facility. Click this link to run a Printing Test to ensure that you will be able to print your completed form. Because of the sensitive nature of the information requested, the information is not saved in your computer or on our web server.


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. You will be provided an opportunity to review and change your information prior to submission. We will begin processing the application upon 1010es of the signed form. Typically, veterans who have NOT previously enrolled or applied for VA health care benefits should use this form.

Therefore, the form must be completed in a single session. 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.