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

Because of the sensitive nature of the information requested, the information is not saved in your computer or on our web server.

VA Health Benefits Application Form (EZ) – VFW Post

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. Instructions for Completing VA Form EZ Vorm 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. Additionally, the online form limits the amount of time your browser can remain idle.


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I have read this page and want to go to the Online Submission Form. Click this link to run a Printing Test to ensure that you will be able to print your completed form. Typically, veterans who have NOT previously enrolled or applied for VA health care benefits should use this form.

If you have delegated someone else to sign the form, we must receive a copy of the Power of Attorney. Do not use the browser ” Back ” and ” Forward ” buttons. If a new window does not appear, please check for a pop-up blocker. Before beginning the online submission 1001ez, we suggest viewing or printing the EZ to assist you in gathering all the information required to complete it. The witnesses must also sign the form and print their names.

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.

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

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


If the form is not signed and dated, VA will return it to the applicant to complete. The forms may not function correctly. To navigate this form, use the buttons provided on each page.

You the applicant must sign and date the printed copy and mail or fax it to the selected VA Facility. Click the “Continue” button promptly to avoid closing your form and erasing the information you have entered. This will result in a delay in processing the application. If your browser does not have scripting enabled, or it does not support it.

You will be provided an opportunity to review and change your information prior to submission. This is a “smart” form 0110ez that it will route you around sections of the form you do not have to complete which is based on the information you enter. You must have the latest version of Adobe Acrobat Reader on your computer to save or print the forms.