10-10EZ Form - va 2025

1. Click ‘Get Form’ to open the 10-10EZ Form in the editor.
2. Begin with Section I, General Information. Fill in your name, social security number, and contact details accurately.
3. Proceed to Section II, Military Service Information. Provide details about your military service, including branch and discharge type.
4. In Section III, Insurance Information, list all health insurance providers covering you. Include policy numbers and group codes.
5. If applicable, complete Section IV for Dependent Information. Include details of your spouse and children under specified conditions.
6. Section V requires reporting previous year's gross annual income for you and your dependents. Be thorough in listing all sources of income.
7. In Section VI, report any non-reimbursed medical expenses from the previous year that you or your spouse incurred.
8. Finally, review Section VII for consent to copays and communications. Ensure you understand the terms before signing.
9. Sign and date the form at the end. If needed, have witnesses sign if you are unable to sign yourself.
10. Submit your completed application by mailing it to the Health Eligibility Center as instructed.

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