2025 VA APPLICATION FOR HEALTH BENEFITS

APPLICATION FOR HEALTH BENEFITS
SECTION I - GENERAL INFORMATION
Federal law provides criminal penalties, including a fine and/or imprisonment for up to 5 years, for concealing a material fact or making a materially false statement. (See 18 U.S.C. 1001)
TYPE OF BENEFIT(S) APPLYING FOR:

ENROLLMENT - VA Medical Benefits Package (Veteran meets and agrees to the enrollment eligibility criteria specified at 38 CFR 17.36)REGISTRATION - (Complete Sections I, II, and III) VA Health Services (Veterans meets the "Enrollment not required" eligibility criteria specified at 38 CFR 17.37)
Contact Email Address*
example@example.com
VETERAN'S NAME (Last, First, Middle Name)*
PREFERRED NAME
MOTHER'S MAIDEN NAME*
BIRTH SEX*

MALEFEMALE
SELF-IDENTIFIED GENDER IDENTITY*

MANWOMANTRANSGENDER MANTRANSGENDER WOMANNON-BINARYPREFER NOT TO ANSWERA GENDER NOT LISTED HERE
ARE YOU HISPANIC OR LATINO?*

YESNO
WHAT IS YOUR RACE? (You may check more than one. Information is required for statistical purposes only)*

ASIANAMERICAN INDIAN OR ALASKA NATIVEBLACK OR AFRICAN AMERICANWHITENATIVE HAWAIIAN OR OTHER PACIFIC ISLANDERCHOOSE NOT TO ANSWER
SOCIAL SECURITY NO.*
DATE OF BIRTH*

MonthDayYear
DATE OF BIRTH (mm/dd/yyyy)*

MonthDayYear
MM/DD/YYYY
PLACE OF BIRTH (City and State)*
PREFERRED LANGUAGE
RELIGION
MAILING ADDRESS (street)*
CITY*
STATE*
ZIP CODE*
COUNTY*
HOME TELEPHONE NO. (optional)
Entry must be 10 charactersFormat: (000) 000-0000.
MOBILE TELEPHONE NO. (optional)
Entry must be 10 charactersFormat: (000) 000-0000.
E MAIL ADDRESS (optional)
Enter in format example@example.com
IS HOME ADDRESS THE SAME AS MAILING ADDRESS?*

YESNO
HOME ADDRESS (Street)*
CITY*
STATE*
ZIP CODE*
COUNTY*
CURRENT MARITAL STATUS*

MARRIEDNEVER MARRIEDSEPARATEDWIDOWEDDIVORCED
NEXT OF KIN NAME*
NEXT OF KIN ADDRESS*
NEXT OF KIN RELATIONSHIP*
NEXT OF KIN TELEPHONE NO. (Include Area Code)*
Entry must be 10 charactersFormat: (000) 000-0000.
EMERGENCY CONTACT NAME*
EMERGENCY CONTACT TELEPHONE NO. (Include Area Code)*
Entry must be 10 charactersFormat: (000) 000-0000.
DESIGNEE INDIVIDUAL TO RECEIVE POSSESSION OF YOUR PERSONAL PROPERTY LEFT ON PREMISES UNDER VA CONTROL AFTER YOUR DEPARTURE OR AT THE TIME OF DEATH (Note: This does not constitute a will or transfer of title)*
WHICH VA MEDICAL CENTER OR OUTPATIENT CLINIC DO YOU PREFER? (for listing of. facilities visit www.va.gov/directory)*
WOULD YOU LIKE FOR VA TO CONTACT YOU TO SCHEDULE YOUR FIRST APPOINTMENT?*

YESNO
SECTION II - MILITARY SERVICE INFORMATION
LAST BRANCH OF SERVICE*
LAST ENTRY DATE*

MonthDayYear
LAST ENTRY DATE

MonthDayYear
MM/DD/YYYY
FUTURE DISCHARGE DATE

MonthDayYear
FUTURE DISCHARGE DATE*

MonthDayYear
MM/DD/YYYY
LAST DISCHARGE DATE*

MonthDayYear
LAST DISCHARGE DATE

MonthDayYear
MM/DD/YYYY
DISCHARGE TYPE*
MILITARY SERVICE NUMBER
MILITARY HISTORY (Check yes or no)
ARE YOU A PURPLE HEART AWARD RECIPIENT?*

YESNO
ARE YOU A FORMER PRISONER OF WAR?*

YESNO
DID YOU SERVE IN A COMBAT THEATER OF OPERATIONS AFTER 11/11/1998?*

YESNO
WERE YOU DISCHARGED OR RETIRED FROM MILITARY FOR A DISABILITY INCURRED IN THE LINE OF DUTY?*

YESNO
DID YOU SERVE IN SW ASIA DURING THE GULF WAR BETWEEN AUGUST 2, 1990 AND NOVEMBER 11, 1998?*

YESNO
DO YOU HAVE A VA SERVICE-CONNECTED RATING?*

YESNO
WHAT IS YOUR RATED PERCENTAGE?
DID YOU SERVE IN AN IONIZING RADIATION LOCATIONAND PARTICIPATE IN ANY NUCLEAR TESTING,TREATMENTS, OR CLEAN UP? (Hiroshima and Nagasaki cleanup or Enewetak Atoll, cleanup of Air Force B-52 bomber carrying nuclear weapons off the coast of Palomares, Spain, response to the fire onboard an Air Force B-52 bomber carrying nuclear weapons near Thule Air Force Base in Greenland.)*

YESNO
DID YOU SERVE IN ANY OF THE FOLLOWING GULF WAR HAZARD LOCATIONS? (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.)*

YesNo
WHEN DID YOU SERVE IN THESE LOCATIONS? NOTE: Please provide an approximate time-frame (mm/yyyy)
From
mm/yyyy
To
mm/yyyy
WERE YOU DEPLOYED IN SUPPORT OF ANY OF THE FOLLOWING OPERATIONS? (Enduring Freedom, Freedom's Sentinel, Iraqi Freedom, New Dawn, Inherent Resolve, and Resolute Support Mission.)

YesNo
DID YOU SERVE IN ANY OF THE FOLLOWING HERBICIDE (e.g. AgentOrange) LOCATIONS? (Republic of Vietnam to include 12 nautical mileterritorial waters; Thailand at any United States or Royal Thai base;Laos; Cambodia at Mimot or Krek; Kampong Cham Province; Guam orAmerican Samoa; or in the territorial waters thereof; Johnston Atoll or aship that called at Johnston Atoll; Korean demilitarized zone; aboard (toinclude repeated operations and maintenance with) a c-123 aircraftknown to have been used to spray an herbicide agent (during service inthe Air Force and Air Force Reserves.)*

YESNO
WHEN DID YOU SERVE IN THESE LOCATIONS? NOTE: Please provide an approximate time-frame (mm/yyyy)
From
mm/yyyy
To
mm/yyyy
HAVE YOU BEEN EXPOSED TO ANY OF THE FOLLOWING? (Check all that apply) Veterans can locate additional military exposure categories on VA’s Public Health website at: https://www.publichealth.va.gov/exposures/

Air Pollutants (burn pits, sand, oil well/sulfur fires)Chemicals (pesticides, herbicides, contaminated water)Contaminated Water at Camp LejeuneRadiationShad (Shipboard Hazard and Defense)Occupational Hazards (jet fuel, industrial solvents, lead, firefighting foams)AsbestosMustard GasWarfare Agents (nerve agents, chemical and biological weapons)Other
WHEN WERE YOU EXPOSED? NOTE: Please provide an approximate time-frame (mm/yyyy)
From
mm/yyyy
To
mm/yyyy
DID YOU RECEIVE NOSE AND THROAT RADIUM TREATMENTS WHILE IN THE MILITARY?*

YESNO
DID YOU SERVE ON ACTIVE DUTY AT LEAST 30 DAYS AT CAMP LEJEUNE FROM AUGUST 1, 1953 THROUGH DECEMBER 31, 1987?*

YESNO
VETERAN'S NAME (Last, First, Middle)*
SOCIAL SECURITY NUMBER*
SECTION III - INSURANCE INFORMATION (Use a separate sheet for additional information)
Do you currently have health insurance?*

YesNo
ENTER YOUR HEALTH INSURANCE COMPANY NAME, ADDRESS AND TELEPHONE NUMBER (include coverage through spouse or other person)*
NAME OF POLICY HOLDER*
POLICY NUMBER*
GROUP CODE*
ARE YOU ELIGIBLE FOR MEDICAID? (Federal health insurance for low income adults)*

YESNO
ARE YOU ENROLLED IN MEDICARE HOSPITAL INSURANCE PART A?*

YESNO
EFFECTIVE DATE*

MonthDayYear
EFFECTIVE DATE

MonthDayYear
MM/DD/YYYY
MEDICARE NUMBER
SECTION IV - DEPENDENT INFORMATION
Spouse Information
SPOUSE'S NAME (Last, First, Middle Name)*
SPOUSE'S SOCIAL SECURITY NUMBER*
SPOUSE'S DATE OF BIRTH (mm/dd/yyyy)*

MonthDayYear
SPOUSE'S DATE OF BIRTH (mm/dd/yyyy)

MonthDayYear
Date
SPOUSE SELF-IDENTIFIED GENDER IDENTITY*

MANWOMANTRANSGENDER MANTRANSGENDER WOMANNON-BINARYPREFER NOT TO ANSWERA GENDER NOT LISTED HERE
DATE OF MARRIAGE (mm/dd/yyyy)*

MonthDayYear
DATE OF MARRIAGE (mm/dd/yyyy)

MonthDayYear
MM/DD/YYYY
IS SPOUSE'S ADDRESS AND/OR TELEPHONE NUMBER DIFFERENT FROM VETERAN'S?

YESNO
SPOUSE'S ADDRESS AND TELEPHONE NUMBER (Street, City, State, ZIP if different from Veteran's)*
Do you have a dependent Child to add?

YesNo
CHILD ONE
2.1 CHILD'S NAME (Last, First, Middle Name)*
2.1.A. CHILD'S DATE OF BIRTH (mm/dd/yyyy)*

MonthDayYear
2.1.A. CHILD'S DATE OF BIRTH (mm/dd/yyyy)

MonthDayYear
MM/DD/YYYY
2.1.B. CHILD'S SOCIAL SECURITY NO.*
2.1.C. DATE CHILD BECAME YOUR DEPENDENT (mm/dd/yyyy)*

MonthDayYear
2.1.C. DATE CHILD BECAME YOUR DEPENDENT (mm/dd/yyyy)

MonthDayYear
Date
2.1.D. CHILD'S RELATIONSHIP TO YOU (Check one)*

SONDAUGHTERSTEPSONSTEPDAUGHTER
2.1.E. WAS CHILD PERMANENTLY AND TOTALLY DISABLED BEFORE THE AGE OF 18?*

YESNO
2.1.F. IF CHILD IS BETWEEN 18 AND 23 YEARS OF AGE, DID CHILD ATTEND SCHOOL LAST CALENDAR YEAR?

YESNO
2.1.G. EXPENSES PAID BY YOUR DEPENDENT CHILD WITH REPORTABLE INCOMEFOR COLLEGE, VOCATIONAL REHABILITATION OR TRAINING (e.g., tuition,books, materials)
Do you have another dependent Child to add?

YesNo
CHILD TWO
2.2 CHILD'S NAME (Last, First, Middle Name)*
2.2.A. CHILD'S DATE OF BIRTH (mm/dd/yyyy)*

MonthDayYear
2.2.A. CHILD'S DATE OF BIRTH (mm/dd/yyyy)

MonthDayYear
MM/DD/YYYY
2.2.B. CHILD'S SOCIAL SECURITY NO.*
2.2.C. DATE CHILD BECAME YOUR DEPENDENT (mm/dd/yyyy)*

MonthDayYear
2.2.C. DATE CHILD BECAME YOUR DEPENDENT (mm/dd/yyyy)

MonthDayYear
MM/DD/YYYY
2.2.D. CHILD'S RELATIONSHIP TO YOU (Check one)*

SONDAUGHTERSTEPSONSTEPDAUGHTER
2.2.E. WAS CHILD PERMANENTLY AND TOTALLY DISABLED BEFORE THE AGE OF 18?*

YESNO
2.2.F. IF CHILD IS BETWEEN 18 AND 23 YEARS OF AGE, DID CHILD ATTEND SCHOOL LAST CALENDAR YEAR?

YESNO
2.2.G. EXPENSES PAID BY YOUR DEPENDENT CHILD WITH REPORTABLE INCOMEFOR COLLEGE, VOCATIONAL REHABILITATION OR TRAINING (e.g., tuition,books, materials)
Do you have another dependent Child to add?

YesNo
CHILD THREE
2.3 CHILD'S NAME (Last, First, Middle Name)*
2.3.A. CHILD'S DATE OF BIRTH (mm/dd/yyyy)*

MonthDayYear
2.3.A. CHILD'S DATE OF BIRTH (mm/dd/yyyy)

MonthDayYear
Date
2.3.B. CHILD'S SOCIAL SECURITY NO.*
2.3.C. DATE CHILD BECAME YOUR DEPENDENT (mm/dd/yyyy)*

MonthDayYear
2.3.C. DATE CHILD BECAME YOUR DEPENDENT (mm/dd/yyyy)

MonthDayYear
Date
2.3.D. CHILD'S RELATIONSHIP TO YOU (Check one)*

SONDAUGHTERSTEPSONSTEPDAUGHTER
2.3.E. WAS CHILD PERMANENTLY AND TOTALLY DISABLED BEFORE THE AGE OF 18?*

YESNO
2.3.F. IF CHILD IS BETWEEN 18 AND 23 YEARS OF AGE, DID CHILD ATTEND SCHOOL LAST CALENDAR YEAR?

YESNO
2.3.G. EXPENSES PAID BY YOUR DEPENDENT CHILD WITH REPORTABLE INCOMEFOR COLLEGE, VOCATIONAL REHABILITATION OR TRAINING (e.g., tuition,books, materials)
Do you have another dependent Child to add?

YesNo
CHILD FOUR
2.4 CHILD'S NAME (Last, First, Middle Name)*
2.4.A. CHILD'S DATE OF BIRTH (mm/dd/yyyy)*

MonthDayYear
2.4.A. CHILD'S DATE OF BIRTH (mm/dd/yyyy)

MonthDayYear
MM/DD/YYYY
2.4.B. CHILD'S SOCIAL SECURITY NO.*
2.4.C. DATE CHILD BECAME YOUR DEPENDENT (mm/dd/yyyy)*

MonthDayYear
2.4.C. DATE CHILD BECAME YOUR DEPENDENT (mm/dd/yyyy)

MonthDayYear
MM/DD/YYYY
2.4.D. CHILD'S RELATIONSHIP TO YOU (Check one)*

SONDAUGHTERSTEPSONSTEPDAUGHTER
2.4.E. WAS CHILD PERMANENTLY AND TOTALLY DISABLED BEFORE THE AGE OF 18?*

YESNO
2.4.F. IF CHILD IS BETWEEN 18 AND 23 YEARS OF AGE, DID CHILD ATTEND SCHOOL LAST CALENDAR YEAR?

YESNO
2.4.G. EXPENSES PAID BY YOUR DEPENDENT CHILD WITH REPORTABLE INCOMEFOR COLLEGE, VOCATIONAL REHABILITATION OR TRAINING (e.g., tuition,books, materials)
Do you have another dependent Child to add?

YesNo
CHILD FIVE
2.5 CHILD'S NAME (Last, First, Middle Name)*
2.5.A. CHILD'S DATE OF BIRTH (mm/dd/yyyy)*

MonthDayYear
2.5.A. CHILD'S DATE OF BIRTH (mm/dd/yyyy)

MonthDayYear
MM/DD/YYYY
2.5.B. CHILD'S SOCIAL SECURITY NO.*
2.5.C. DATE CHILD BECAME YOUR DEPENDENT (mm/dd/yyyy)*

MonthDayYear
2.5.C. DATE CHILD BECAME YOUR DEPENDENT (mm/dd/yyyy)

MonthDayYear
MM/DD/YYYY
2.5.D. CHILD'S RELATIONSHIP TO YOU (Check one)*

SONDAUGHTERSTEPSONSTEPDAUGHTER
2.5.E. WAS CHILD PERMANENTLY AND TOTALLY DISABLED BEFORE THE AGE OF 18?*

YESNO
2.5.F. IF CHILD IS BETWEEN 18 AND 23 YEARS OF AGE, DID CHILD ATTEND SCHOOL LAST CALENDAR YEAR?

YESNO
2.5.G. EXPENSES PAID BY YOUR DEPENDENT CHILD WITH REPORTABLE INCOMEFOR COLLEGE, VOCATIONAL REHABILITATION OR TRAINING (e.g., tuition,books, materials)
3. IF YOUR SPOUSE OR DEPENDENT CHILD DID NOT LIVE WITH YOU LAST YEAR, DID YOU PROVIDE SUPPORT?

YESNO
SECTION V - EMPLOYMENT INFORMATION
VETERAN'S EMPLOYMENT STATUS (Check one)

FULL TIMEPART TIMENOT EMPLOYEDRETIRED
DATE OF RETIREMENT*

MonthDayYear
DATE OF RETIREMENT

MonthDayYear
MM/DD/YYYY
COMPANY NAME*
(Complete if employed or retired)
COMPANY ADDRESS*
(Complete if employed or retired - Street, City, State, ZIP )
COMPANY PHONE NUMBER*
Complete if employed or retired, include area code
SECTION VI - FINANCIAL DISCLOSURE
Disclosure allows VA to accurately determine whether certain Veterans will be charged copays for care and medications, their eligibility for other services and enrollment priority. Veterans are not required to disclose their financial information. Veterans who choose not to disclose financial information may not be eligible for enrollment or may be responsible for any applicable VA copayments, if they are enrolled. Recent Combat Veterans (e.g., OEF/OIF/OND) may answer YES in Section VI and complete Sections VII and VIII to have their priority for enrollment and financial eligibility for travel assistance, cost-free medications and/or medical care for services unrelated to military experience.
Will you provide your household financial information?

No, I do not wish to provide financial information in Sections VII through VIII. If I am enrolled, I agree to pay applicable VA copayments. Sign and date the form in the Assignment of Benefits sectionYes, I will provide my household financial information for last calendar year. Complete applicable Sections VII and VIII. Sign and date the form in the Assignment of Benefits section.
SECTION VII - PREVIOUS CALENDAR YEAR GROSS ANNUAL INCOME OF VETERAN, SPOUSE AND DEPENDENT CHILDREN

PREVIOUS CALENDAR YEAR GROSS ANNUAL INCOME OF VETERAN, SPOUSE AND DEPENDENT CHILDREN - * Gross Income Must Be Included Or Your Application May Be Rejected

Rows	Veteran	Spouse	Child1	Child2	Child3	Child4	Child5
1. Gross Annual Income from employment(wages, bonuses, tips, etc) excluding income from your farm, ranch, property or business
2. Net income from your farm, ranch, property or business
3. List other income amounts(e.g. Social Security , compensation, pension, interest, dividends) excluding welfare

SECTION VIII - PREVIOUS CALENDAR YEAR DEDUCTIBLE EXPENSES
1. TOTAL NON REIMBURSED MEDICAL EXPENSES PAID BY YOU OR YOUR SPOUSE (e.g., payments for doctors, dentists, medications, Medicare, health insurance, hospital and nursing home) * All medical expenses to include over the counter as well as copays and premiums for the household. VA will calculate a deductible and the net medical expenses you may claim.
2. AMOUNT YOU PAID LAST CALENDAR YEAR FOR FUNERAL AND BURIAL EXPENSES (INCLUDING PREPAID BURIAL EXPENSES) FOR YOUR DECEASED SPOUSE OR DEPENDENT CHILD (Also enter spouse or child's information in Section VI.)
3 . AMOUNT YOU PAID LAST CALENDAR YEAR FOR YOUR COLLEGE OR VOCATIONAL EDUCATIONAL EXPENSES (e.g., tuition, books, fees, materials) DO NOT LIST YOUR DEPENDENTS' EDUCATIONAL EXPENSES.
VETERAN'S NAME (Last, First, Middle)
SOCIAL SECURITY NUMBER
SECTION IX - CONSENT TO COPAYS AND TO RECEIVE COMMUNICATIONS
By submitting this application, you are agreeing to pay the applicable VA copayments for care or services (including urgent care) as required by law. You also agree to receive communications from VA to your supplied email, home phone number, or mobile number. However, providing your email, home phone number, or mobile number is voluntary.
ASSIGNMENT OF BENEFITS
I understand that pursuant to 38 U.S.C. Section 1729 and 42 U.S.C. 2651, the Department of Veterans Affairs (VA) is authorized to recover or collect from my health plan (HP) or any other legally responsible third party for the reasonable charges of nonservice-connected VA medical care or services furnished or provided to me. I hereby authorize payment directly to VA from any HP under which I am covered (including coverage provided under my spouse's HP) that is responsible for payment of the charges for my medical care, including benefits otherwise payable to me or my spouse. Furthermore, I hereby assign to the VA any claim I may have against any person or entity who is or may be legally responsible for the payment of the cost of medical services provided to me by the VA. I understand that this assignment shall not limit or prejudice my right to recover for my own benefit any amount in excess of the cost of medical services provided to me by the VA or any other amount to which I may be entitled. I hereby appoint the Attorney General of the United States and the Secretary of Veterans' Affairs and their designees as my Attorneys-in-fact to take all necessary and appropriate actions in order to recover and receive all or part of the amount herein assigned. I hereby authorize the VA to disclose, to my attorney and to any third party or administrative agency who may be responsible for payment of the cost of medical services provided to me, information from my medical records as necessary to verify my claim. Further, I hereby authorize any such third party or administrative agency to disclose to the VA any information regarding my claim.

ALL APPLICANTS MUST SIGN AND DATE THIS FORM. REFER TO INSTRUCTIONS WHICH DEFINE WHO CAN SIGN ON BEHALF OF THE VETERAN.
SIGNATURE OF APPLICANT
Signature of Applicant

Clear
Use your mouse, touchpad, or touchscreen in the area above to provide your signature.
DATE*

MonthDayYear
DATE

MonthDayYear
MM/DD/YYYY
Should be Empty:

APPLICATION FOR HEALTH BENEFITS

SECTION I - GENERAL INFORMATION

SECTION II - MILITARY SERVICE INFORMATION

MILITARY HISTORY (Check yes or no)

WHEN DID YOU SERVE IN THESE LOCATIONS? NOTE: Please provide an approximate time-frame (mm/yyyy)

WHEN DID YOU SERVE IN THESE LOCATIONS? NOTE: Please provide an approximate time-frame (mm/yyyy)

WHEN WERE YOU EXPOSED? NOTE: Please provide an approximate time-frame (mm/yyyy)

SECTION III - INSURANCE INFORMATION (Use a separate sheet for additional information)

SECTION IV - DEPENDENT INFORMATION

Spouse Information

CHILD ONE

CHILD TWO

CHILD THREE

CHILD FOUR

CHILD FIVE

SECTION V - EMPLOYMENT INFORMATION

SECTION VI - FINANCIAL DISCLOSURE

SECTION VII - PREVIOUS CALENDAR YEAR GROSS ANNUAL INCOME OF VETERAN, SPOUSE AND DEPENDENT CHILDREN

SECTION VIII - PREVIOUS CALENDAR YEAR DEDUCTIBLE EXPENSES

SECTION IX - CONSENT TO COPAYS AND TO RECEIVE COMMUNICATIONS

ASSIGNMENT OF BENEFITS

SIGNATURE OF APPLICANT