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 have delegated someone else to sign the form, we must receive a 0110ez of the Power of Attorney. The witnesses must also sign the form and print their names. Do not use the browser ” Back ” and ” Forward ” buttons. This flrm 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.

Click this link to run a Printing Test to ensure that you will be able to print your completed form. Click the “Continue” button promptly to avoid closing your form and erasing the information you have entered.

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 your browser does not have scripting enabled, or it does not support it.


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.

Click here to obtain a free copy of the Adobe Acrobat Reader software. 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. To navigate this form, use the buttons provided on each page. You must have the latest version of Adobe Acrobat Reader on your computer to save or print the forms. Typically, veterans who have NOT previously enrolled or applied for VA health care benefits should use this form.

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

Enter your search text Button to start search. If a new window does not appear, please check for a pop-up blocker. 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.

Before beginning the forj submission process, we suggest viewing or printing the EZ to assist you in gathering all the information required to complete it. This will result in a delay in processing the application.


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Because of the sensitive nature of the information requested, the information is not saved in your computer or on our web server. Additionally, the online form limits ofrm amount of time your browser can remain idle.

We will begin processing the application upon receipt of the signed form.

If you do not see the words “Print test successful”you should check to make sure that Acrobat Reader has been installed. I have read this fofm and want to go to the Online Submission Form.

You the applicant must sign and date the printed copy and mail or fax it to the selected VA Facility. You will be provided an opportunity to review and change your information prior to submission.

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

The forms may not function correctly. If the form is not signed and dated, VA will return it to the applicant to complete.

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