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What is VA Form EZR used for? Ask VA to help you fill out the form by calling us at VETS (). Access our website at and. Fill va form 10 10ezr va instantly, download blank or editable online. Sign, fax and printable from PC, iPad, tablet or mobile. No software. Try Now!. Form, VA Form EZR, Health Benefits Renewal Form ยท ezr-fill-JUL08 , , Yes, No, Fillable Printable. Form and.

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To navigate this form, use the buttons provided on each page.

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

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

If you have delegated someone else to sign the form, we must receive a copy of the Power of Attorney. If a new window does not appear, please check for a pop-up blocker.


You the applicant must sign and date the printed copy 1e0zr mail or fax it to the selected VA Facility. I have read this page and want to go to the Online Submission Form.

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

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If you do not see the words “Print test successful”you should check to make sure that Acrobat Reader has been installed.

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The witnesses must also sign the form and print their names. You must have the latest version of Adobe Acrobat Reader on your computer to save or print the forms.

Therefore, the form must be completed in a single session. Click this link to run a Printing Test to ensure that you will be able to print your completed 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 10ezf form.

Typically, veterans who have NOT previously enrolled or applied for VA health care benefits should use this form.

We will begin processing the application upon receipt of the signed 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. This will result in a delay in processing the application. Do not use the browser ” Back ” and ” Forward ” buttons. If the form is not signed and dated, VA will return it to the applicant to complete. You will be provided an opportunity to review and change your information prior to submission.

If your browser does not have scripting enabled, or it does not support it. This is a “smart” form in that it will route you around sections of the 10szr you do not have to complete which is based on the information you enter. 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.