Registry entry

United States VA Health Care Enrollment Application (Form 10-10EZ)

Apply for enrollment in the U.S. Department of Veterans Affairs (VA) health care system, or for VA health services requiring only registration, using Form 10-10EZ. Models the base form's inline capacity: General Information, Military Service Information (including a military-exposure/TERA branch relevant to VA's priority-group and toxic-exposure determinations), Insurance Information, Dependent Information (one spouse and one dependent child; the source form directs claims for additional dependents to a separate continuation sheet), Employment Information, the Financial Disclosure opt-in/opt-out gating Sections VII-VIII (previous-calendar-year income and deductible expenses), and the consent/signature section. Does not model: the online va.gov application wizard (this document is sourced from the static fillable PDF, which VA's own instructions treat as collecting the same information as the online channel), additional dependents beyond one spouse and one child, or the separate VA Form 10-10EZR (health benefits renewal/update, for Veterans already enrolled). Does not submit the application; the live va.gov 'Apply for VA health care' online service and the mailed paper form are always authoritative.

Registry entry

us/va/health-benefits-enrollment-10-10ez

Jurisdiction
United States · national
Version
1.0.0
Verification
draft
Authority
U.S. Department of Veterans Affairs, Veterans Health Administration

GovSchema spec v0.3

Authoritative source VA Form 10-10EZ (FEB 2025 edition) — Application for Health Benefits; OMB Control No. 2900-0091

Machine access

Schema document
registry/us/va/health-benefits-enrollment-10-10ez/1.0.0/schema.jsonapplication/schema+json
Verification record
registry/us/va/health-benefits-enrollment-10-10ez/1.0.0/VERIFICATION.mdtext/markdown
Registry catalog
registry/index.jsonone record per schema id

Field reference

105 fields across 8 steps, read from the published schema.json — names, types, requiredness, and validation as the document states them. The live government form remains the authoritative source.

Section I — General information

  • typeOfBenefitApplyingFor enum required

    Enrollment: VA Medical Benefits Package under 38 CFR 17.36. Registration: VA Health Services under the 'enrollment not required' eligibility criteria of 38 CFR 17.37 (only Sections I-III need be completed).

    enum: enrollment | registration
  • veteranFullName string required

    Veteran's name (Last, First, Middle Name)

    length: 1–200classification: pii
  • preferredName string optional

    Preferred name

    length: 0–100classification: pii
  • mothersMaidenName string optional

    Mother's maiden name

    length: 0–100classification: pii
  • sex enum required

    Sex

    enum: female | maleclassification: pii
  • raceEthnicity enum optional

    Collected for statistical purposes only. The source form allows checking more than one box; this document models the single primary selection.

    enum: 8 values
  • socialSecurityNumber string required

    Social Security number

    patternclassification: sensitive-pii
  • dateOfBirth date required

    Date of birth

    classification: sensitive-pii
  • placeOfBirth string optional

    Place of birth (city and state)

    length: 0–200classification: pii
  • preferredLanguage string optional

    Preferred language

    length: 0–100
  • religion string optional

    Religion

    length: 0–100classification: pii
  • mailingAddressStreet string required

    Mailing address — street

    length: 1–200classification: pii
  • mailingAddressCity string required

    Mailing address — city

    length: 1–100classification: pii
  • mailingAddressState string required

    Mailing address — state

    length: 1–2classification: pii
  • mailingAddressZipCode string required

    Mailing address — ZIP code

    patternclassification: pii
  • mailingAddressCounty string optional

    Mailing address — county

    length: 0–100classification: pii
  • homePhone string optional

    Home telephone number (optional)

    pattern
  • mobilePhone string optional

    Mobile telephone number (optional)

    pattern
  • emailAddress string optional

    Email address (optional)

    length: 0–254
  • homeAddressSameAsMailing boolean required

    Inferred gate: the source form prints separate mailing (9) and home (10) address blocks without a printed shortcut, so this document adds an explicit boolean per this registry's convention.

  • homeAddressStreet string optional

    Home address — street

    length: 0–200classification: pii
  • homeAddressCity string optional

    Home address — city

    length: 0–100classification: pii
  • homeAddressState string optional

    Home address — state

    length: 0–2classification: pii
  • homeAddressZipCode string optional

    Home address — ZIP code

    patternclassification: pii
  • homeAddressCounty string optional

    Home address — county

    length: 0–100classification: pii
  • currentMaritalStatus enum required

    Current marital status

    enum: married | never_married | separated | widowed | divorced
  • nextOfKinName string optional

    Next of kin — name

    length: 0–200classification: pii
  • nextOfKinAddress string optional

    Next of kin — address

    length: 0–300classification: pii
  • nextOfKinRelationship string optional

    Next of kin — relationship

    length: 0–100
  • nextOfKinPhone string optional

    Next of kin — telephone number

    pattern
  • emergencyContactName string optional

    Emergency contact — name

    length: 0–200classification: pii
  • emergencyContactPhone string optional

    Emergency contact — telephone number

    pattern
  • designee string optional

    Does not constitute a will or transfer of title.

    length: 0–200classification: pii
  • preferredVaFacility string optional

    Which VA medical center or outpatient clinic do you prefer?

    length: 0–200
  • wantsFirstAppointmentContact boolean required

    Would you like VA to contact you to schedule your first appointment?

Section II — Military service information

  • lastBranchOfService string required

    Last branch of service

    length: 1–100
  • lastEntryDate date required

    Last entry date

  • futureDischargeDate date optional

    Future discharge date

  • lastDischargeDate date optional

    Last discharge date

  • dischargeType string optional

    Discharge type

    length: 0–100
  • militaryServiceNumber string optional

    Military service number

    length: 0–50classification: pii
  • isPurpleHeartRecipient boolean required

    Are you a Purple Heart award recipient?

  • isFormerPow boolean required

    Are you a former Prisoner of War?

  • servedCombatTheaterAfter1998 boolean required

    Did you serve in a combat theater of operations after 11/11/1998?

  • dischargedForServiceConnectedDisability boolean required

    Were you discharged or retired from military for a disability incurred in the line of duty?

  • servedGulfWar1990to1998 boolean required

    Did you serve in SW Asia during the Gulf War between August 2, 1990 and November 11, 1998?

  • hasVaServiceConnectedRating boolean required

    Do you have a VA service-connected rating?

  • servedIonizingRadiationLocation boolean required

    Example locations: Hiroshima and Nagasaki cleanup, Enewetak Atoll, response to nuclear-weapons-carrying B-52 incidents at Palomares, Spain and Thule Air Force Base, Greenland.

  • servedGulfWarHazardLocation boolean required

    Iraq, Kuwait, Saudi Arabia, the neutral zone between Iraq and Saudi Arabia, Bahrain, Qatar, the United Arab Emirates, Oman, Yemen, Lebanon, Somalia, Afghanistan, Israel, Egypt, Turkey, Syria, Jordan, Djibouti, Uzbekistan, the Gulf of Aden, the Gulf of Oman, the Persian Gulf, the Arabian Sea, and the Red Sea.

  • gulfWarHazardServiceFrom string optional

    Gulf War hazard location service — from (approximate MM/YYYY)

    pattern
  • gulfWarHazardServiceTo string optional

    Gulf War hazard location service — to (approximate MM/YYYY)

    pattern
  • deployedInSupportOfNamedOperations boolean required

    Were you deployed in support of Enduring Freedom, Freedom's Sentinel, Iraqi Freedom, New Dawn, Inherent Resolve, or Resolute Support Mission?

  • servedHerbicideLocation boolean required

    Republic of Vietnam (incl. 12 nautical mile territorial waters), Thailand at a US/Royal Thai base, Laos, specific Cambodia locations, Guam/American Samoa, Johnston Atoll, Korean demilitarized zone, or aboard a C-123 aircraft known to have sprayed herbicide agent.

  • herbicideServiceFrom string optional

    Herbicide location service — from (approximate MM/YYYY)

    pattern
  • herbicideServiceTo string optional

    Herbicide location service — to (approximate MM/YYYY)

    pattern
  • exposureCategory enum optional

    The source form allows checking more than one box; this document models the single primary category. See VA's Public Health website (publichealth.va.gov/exposures) for additional exposure categories.

    enum: 10 values
  • exposureCategoryOtherDescription string optional

    Description of other exposure

    length: 1–200
  • exposureServiceFrom string optional

    Meaningful only if exposureCategory is answered; not encoded as a requiredWhen since exposureCategory is itself optional with no printed yes/no gate.

    pattern
  • exposureServiceTo string optional

    Meaningful only if exposureCategory is answered.

    pattern

Section III — Insurance information

  • hasHealthInsurance boolean required

    Inferred gate: Section III's fields are only meaningful if the applicant has coverage to declare.

  • healthInsuranceCompanyDetails string optional

    Include coverage through a spouse or other person.

    length: 0–300
  • policyHolderName string optional

    Name of policy holder

    length: 0–200classification: pii
  • policyNumber string optional

    Policy number

    length: 0–50classification: sensitive-pii
  • groupCode string optional

    Group code

    length: 0–50
  • eligibleForMedicaid boolean required

    Are you eligible for Medicaid?

  • enrolledInMedicarePartA boolean required

    Are you enrolled in Medicare Hospital Insurance Part A?

  • medicarePartAEffectiveDate date optional

    Medicare Part A effective date

  • medicareNumber string optional

    Medicare number

    length: 0–30classification: sensitive-pii

Section IV — Dependent information

  • hasSpouse boolean required

    Include a spouse even if you did not live together, as long as you contributed support last calendar year. Inferred gate for the spouse fields.

  • spouseFullName string optional

    Spouse's name (Last, First, Middle Name)

    length: 0–200classification: pii
  • spouseSocialSecurityNumber string optional

    Spouse's Social Security number

    patternclassification: sensitive-pii
  • spouseDateOfBirth date optional

    Spouse's date of birth

    classification: sensitive-pii
  • spouseSex enum optional

    Spouse's sex

    enum: male | female
  • dateOfMarriage date optional

    Date of marriage

  • spouseAddressAndPhone string optional

    Spouse's address and telephone number, if different from Veteran's

    length: 0–300classification: pii
  • supportedNonresidentSpouseOrChild boolean optional

    If your spouse or dependent child did not live with you last year, did you provide support?

  • hasChild boolean required

    Biological, adopted, and stepchildren who are unmarried and under 18, or at least 18 but under 23 and attending school (full or part-time), or became permanently unable to support themselves before age 18. This document models one child inline, matching the base form's printed capacity ('use a separate sheet for additional dependents').

  • childFullName string optional

    Child's name (Last, First, Middle Name)

    length: 0–200classification: pii
  • childDateOfBirth date optional

    Child's date of birth

    classification: sensitive-pii
  • childSocialSecurityNumber string optional

    Child's Social Security number

    patternclassification: sensitive-pii
  • dateChildBecameDependent date optional

    Date child became your dependent

  • childRelationshipToVeteran enum optional

    Child's relationship to you

    enum: son | daughter | stepson | stepdaughter
  • childPermanentlyDisabledBefore18 boolean optional

    Was child permanently and totally disabled before the age of 18?

  • childAttendedSchoolLastYear boolean optional

    If child is between 18 and 23 years of age, did child attend school last calendar year?

  • childCollegeVocationalExpensesPaidByChild number optional

    For example, tuition, books, materials.

    range: 0–∞

Section V — Employment information

  • veteranEmploymentStatus enum required

    Veteran's employment status

    enum: full_time | part_time | not_employed | retired
  • dateOfRetirement date optional

    Date of retirement

  • employerCompanyName string optional

    Completed if employed or retired.

    length: 0–200
  • employerCompanyAddress string optional

    Completed if employed or retired.

    length: 0–300
  • employerCompanyPhone string optional

    Completed if employed or retired.

    pattern

Section VI — Financial disclosure

  • wantsToDiscloseFinancialInfo boolean required

    Financial disclosure is not required, but VA is not currently enrolling new applicants who decline unless they have other qualifying eligibility factors (e.g. former POW, Purple Heart recipient, recently discharged combat Veteran, TERA service, disability discharge, VA service-connected disability compensation, VA pension, Medicaid, Agent Orange exposure location, SW Asia Gulf War service, or 30+ days at Camp Lejeune between 1953-1987).

Sections VII-VIII — Income and deductible expenses

  • veteranGrossEmploymentIncome number optional

    Veteran — gross annual income from employment (excluding farm/ranch/property/business)

    range: 0–∞
  • veteranNetFarmRanchIncome number optional

    Veteran — net income from farm, ranch, property, or business

    range: 0–∞
  • veteranOtherIncome number optional

    Excludes welfare.

    range: 0–∞
  • spouseGrossEmploymentIncome number optional

    Spouse — gross annual income from employment

    range: 0–∞
  • spouseNetFarmRanchIncome number optional

    Spouse — net income from farm, ranch, property, or business

    range: 0–∞
  • spouseOtherIncome number optional

    Spouse — other income amounts

    range: 0–∞
  • childGrossEmploymentIncome number optional

    Include the child's income information if it could have been used to pay household expenses.

    range: 0–∞
  • childNetFarmRanchIncome number optional

    Child — net income from farm, ranch, property, or business

    range: 0–∞
  • childOtherIncome number optional

    Child — other income amounts

    range: 0–∞
  • nonReimbursedMedicalExpenses number optional

    E.g. payments for doctors, dentists, medications, Medicare, health insurance, hospital and nursing home. Do not list expenses you expect to be reimbursed for. VA calculates a deductible and the net medical expenses you may claim.

    range: 0–∞
  • funeralBurialExpensesPaid number optional

    Including prepaid burial expenses. Also enter the spouse or child's information in Section IV.

    range: 0–∞
  • educationalExpensesPaid number optional

    E.g. tuition, books, fees, materials. Do not list dependents' educational expenses.

    range: 0–∞

Verification record

This file is the source-review record for this document version, per the manual-source-review-v1 practice.

Current claim

  • status: draft
  • verification.method: manual-source-review-v1
  • verification.lastVerifiedAt: 2026-07-03

draft, not verified, because no live walkthrough of the va.gov online application wizard was performed — see "What was not done" below. This schema is sourced directly from VA's own current-edition fillable PDF.

Sources examined

  • Document (id, version): us/va/health-benefits-enrollment-10-10ez / 1.0.0
  • Spec version: GovSchema 0.3.0
  • Authority: U.S. Department of Veterans Affairs (VA), Veterans Health Administration.
  • https://www.va.gov/find-forms/about-form-10-10ez/ — reachable directly (HTTP 200, no bot-block encountered), linking to https://www.va.gov/vaforms/medical/pdf/VA Form 10-10EZ.pdf (the space in the URL path required percent-encoding, %20).
  • VA Form 10-10EZ.pdf — FEB 2025 edition (the current edition at the time of this review), retrieved via curl (HTTP 200, 1,267,392 bytes) and processed with a scratch npm install of pdfjs-dist (legacy build). This is a genuine fillable AcroForm/XFA PDF, so — beyond the standard page-by-page text-layer extraction used for this registry's other PDF-sourced schemas — this document's fields were also cross-referenced against the PDF's own form-field annotations, retrieved via page.getAnnotations() (name + type, e.g. F[0].P4[0].SSN[0] [Tx], F[0].P4[0].BirthSex[0] [Btn]). Every field's sourceRef in this document cites both the printed question number/label and this internal PDF field name, following the precedent set by au/aec/voter-enrolment's PDF field-name extraction technique — giving this document unusually direct field-level traceability. All 6 pages were extracted: page 1 (general instructions and background on Enrollment vs. Registration), page 2 (Sections IV-IX instructions), page 3 (submission instructions, Paperwork Reduction Act and Privacy Act notices), and pages 4-6 (the fillable form itself: Sections I-IX and the signature block).

What was not done — the one honest gap

No live walkthrough of the va.gov online "Apply for VA health care" wizard was performed. VA's own form instructions (page 1) state the paper form and online application collect the same underlying eligibility information ("For Veterans to apply for enrollment in the VA health care system"), so this document treats the static PDF — directly reachable and field-name traceable — as the faithful source, the same choice made for this registry's other PDF-sourced schemas when a live wizard could not be independently walked through this cycle.

Test run performed

Phase 4 of this cycle's research brief calls for a test run with valid mock data. A scratch Node script (/tmp/va-test/mocktest.mjs, not checked into the registry) implements the GSP-0013 condition grammar (equals/in/all/any/not) and resolves visibleWhen/requiredWhen against two independent mock applicants:

  1. A single Veteran with no dependents, applying for Registration only, no claimed exposures, employed full-time, and declining financial disclosure.
  2. A married Veteran with one dependent child, retired, claiming Gulf War hazard-location and herbicide-location exposure (each exercising its own from/to date pair), health insurance and Medicare Part A enrollment, and opting into financial disclosure (exercising the per-person Veteran/spouse/child income fields and the deductible-expenses section).

Both scenarios: (a) supply every field that is required given its resolved visibility, (b) pass each field's own validation (pattern/enum/min-max), and (c) contain no reference to a field name absent from fields[] across every visibleWhen, requiredWhen, documents[] requiredWhen, and steps[].fields entry. Both passed after one iteration (the first run surfaced two genuine mock-data gaps — a missing homeAddressCounty for a Veteran whose home address differs from her mailing address, and missing employer details for a retired Veteran, since the source form requires employer information for "employed or retired" — both were mock-data omissions, not schema defects, and were corrected).

The schema also validates against both the zero-dependency structural checker (tools/validate.mjs) and the full JSON Schema draft 2020-12 meta-schema via ajv (tools/validate-ajv.mjs).

Modelling decisions

  • Models one spouse and one dependent child inline, matching the base form's own printed capacity (Section IV: "1. SPOUSE'S NAME" and "2. CHILD'S NAME", with "Use a separate sheet for additional dependents" printed at the top of the section) — the same "up to N inline, continue on a separate sheet" pattern this registry already uses for gb/hmrc/child-benefit-claim-ch2 (2 children) and in/mca/company-incorporation-spice-plus.
  • homeAddressSameAsMailing is an inferred gating boolean, not a printed form field. The source prints separate Mailing Address (9) and Home Address (10) blocks with no shortcut checkbox; this document follows this registry's convention (au/aec/voter-enrolment, in/eci/voter-registration) of adding an explicit boolean where GovSchema's grammar needs one but the source form doesn't print one.
  • hasHealthInsurance, hasSpouse, and hasChild are likewise inferred gating booleans for the same reason — Sections III and IV have no printed "do you have insurance/a spouse/a child" yes/no box, only fields that are meaningless if left blank.
  • raceEthnicity, employmentStatus-adjacent fields, and exposureCategory modelled as single-value enums, not multi-select. The source form explicitly allows checking more than one race/ethnicity box (4. WHAT IS YOUR RACE/ETHNICITY?) and more than one exposure category (3E), but GovSchema's enum validation keyword accepts one value per field; documented in each field's own description as a simplification, matching the same choice made for gb/hmrc/child-benefit-claim-ch2's employmentStatus/partnerEmploymentStatus fields.
  • **Military-exposure date pairs (gulfWarHazardService*, herbicideService*, exposureService*) modelled as MM/YYYY strings, not date type.** The source form explicitly asks only for "an approximate time-frame (MM/YYYY)" for each exposure window, so a full ISO date would overspecify precision the source form does not collect — matching the same choice made for in/eci/voter-registration's ordinarilyResidentSinceMonthYear.
  • exposureServiceFrom/exposureServiceTo left unconditionally optional, not gated by requiredWhen on exposureCategory, since exposureCategory itself has no printed yes/no gate (Section 3E is a bare "check all that apply" checklist) — documented in each field's own description rather than forced into an imprecise condition, the same class of gap noted in in/eci/voter-registration's VERIFICATION.md for its own at-least-one-of rule.
  • employerCompanyName/Address/Phone required when veteranEmploymentStatus is full_time, part_time, or retired, matching the source's own printed instruction "(Complete if employed or retired)" — not_employed is the only status that excludes these fields.
  • Social Security number format (^[0-9]{3}-[0-9]{2}-[0-9]{4}$) and 10-digit US phone format (^\([0-9]{3}\) [0-9]{3}-[0-9]{4}$) taken directly from the source form's own printed field masks (e.g. "(999) 999-9999", "999-99-9999").
  • Section VI's Yes/No financial-disclosure choice (wantsToDiscloseFinancialInfo) gates Sections VII-VIII's fields. Sections VII (income) and VIII (deductible expenses) are printed immediately below Section VI's opt-in/opt-out choice and are only meaningful if the Veteran opts to disclose — modelled with requiredWhen/visibleWhen accordingly. The per-person income breakdown (Veteran/Spouse/Child columns in Section VII) is further gated on hasSpouse/hasChild so a single Veteran with no dependents isn't asked for spouse/child income.
  • Office-use-only markings (VA DATE STAMP box, "For VHA Use Only") not modelled — completed by VA staff processing the application, not by the applicant.

Out of scope

  • The online va.gov application wizard — not independently walked through this cycle; see "What was not done" above.
  • Additional dependents beyond one spouse and one dependent child — the source form itself directs claims for more dependents to "a separate sheet," a distinct continuation artifact not modelled here.
  • VA Form 10-10EZR (Health Benefits Renewal/Update Form) — a distinct form for Veterans already enrolled in VA health care to update their information, linked from the same publication page but not itself an enrollment application.
  • Power of Attorney delegated signing, and the "signed with an 'X' plus two witnesses" alternative signing path — both referenced in the source's submission instructions but not modelled as further schema fields; signatureOfApplicant's description documents the rule in prose.

Re-verification

Per the practice's cadence, nextReviewBy is set to 2027-01-03 (6 months). Re-fetch VA Form 10-10EZ to check for an edition update, and attempt a live walkthrough of the va.gov online application wizard if feasible; if the field set matches, promote status to verified.

View the raw record (VERIFICATION.md)

Version history

  • 1.0.0 draft latest this page has verification record schema.json

Independent and non-affiliated

GovSchema is an independent, open-source project. This reference is not produced, reviewed, or endorsed by U.S. Department of Veterans Affairs, Veterans Health Administration or any government. The authoritative source is always the live government form and its official instructions.