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OMB Control No: 2900-0091	ICR Reference No: 202603-2900-018
Status: Historical Inactive	Previous ICR Reference No: 202504-2900-005
Agency/Subagency: VA	Agency Tracking No: VHA-2900-0091
Title: VA Health Benefits: Application, Update, Hardship Determination - VA Forms 10-10EZ,10-10EZR, 10-10HS
Type of Information Collection: No material or nonsubstantive change to a currently approved collection	Common Form ICR: No
Type of Review Request: Regular
OIRA Conclusion Action: Improperly submitted and continue	Conclusion Date: 05/21/2026
	Date Received in OIRA: 04/30/2026
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	07/31/2027	07/31/2027	07/31/2027
Responses	1,406,000	0	1,406,000
Time Burden (Hours)	703,300	0	703,300
Cost Burden (Dollars)	0	0	0

Abstract: Title 38 U.S.C. Chapter 17 authorizes VA to provide hospital care, medical services, domiciliary care, and nursing home care to eligible Veterans. Title 38 U.S.C. § 1705 requires VA to design, establish, and operate a system of annual patient enrollment in accordance with a series of stipulated priorities. Title 38 U.S.C. § 1722 establishes eligibility assessment procedures for cost-free VA medical care, based on income levels, which determines whether nonservice-connected and 0% service-connected non-compensable Veterans are able to defray the necessary expenses of care for nonservice-connected conditions. Further, when the Veteran projects that his or her attributable income for the current calendar year would be substantially below the applicable income thresholds, the Veteran would be considered unable to defray the expenses of care and VA may exempt the Veteran from the requirement to pay copayments for hospital or outpatient care. In addition, Section 103 of Public Law 117-168, titled the Sergeant First Class Heath Robinson Honoring our Promise to Address Comprehensive Toxics (PACT) Act of 2022, amended Title 38 U.S.C. Section 1710(e) (3), by expanding the health care eligibility benefit for Veterans who participated in a toxic exposure risk activity (TERA) while serving on active duty, active duty for training, or inactive duty training. This collection of information is required to properly administer health benefits to eligible Veterans: a. VA Form 10-10EZ, Application for Health Benefits, is used to collect Veteran information during the initial application process for VA medical care, nursing home, domiciliary, dental benefits, etc. b. VA Form 10-10EZR, Health Benefits Update Form, is used to update a Veteran’s personal information, such as marital status, address, health insurance and financial information, for renewal of health benefits. c. VA Form 10-10HS, Request for Hardship Determination, is used to collect information from Veterans who are in a copay required status for hospital care and medical services, but due to a loss of income project their income for the current year will be substantially below the VA means test limits. These forms collect information to enroll a Veteran for health benefits, establish basic eligibility, determine TERA benefit eligibility, identify 3rd party health insurance coverage, identify prescription copayment, provide for income verification, and serve as a mechanism to make changes upon admission for benefits or yearly financial updates. VA Form 10-10EZR has been updated to match the Race/Ethnicity field in VA Form 10-10EZ, which will allow applicants to make any necessary changes to this information. There are no changes to the respondent or burden numbers as a result of this update.

Authorizing Statute(s): PL: Pub.L. 117 - 168 103 Name of Law: Sergeant First Class Heath Robinson Honoring our Promise to Address Comprehensive Toxics (PACT) Act
US Code: 38 USC Chapter 17 Name of Law: HOSPITAL, NURSING HOME, DOMICILIARY,

Citations for New Statutory Requirements: PL: Pub.L. 115 - 182 101 Name of Law: MISSION Act of 2018

Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	89 FR 20537	03/22/2024
30-day Notice:	Federal Register Citation:	Citation Date:
	89 FR 47684	06/03/2024
Did the Agency receive public comments on this ICR? No

Number of Information Collection (IC) in this ICR: 3

IC Title	Form No.	Form Name
VA Form 10-10EZ	10-10EZ
VA Form 10-10EZR	10-10EZR , 10-10EZR	,
VA Form 10-10HS	10-10HS

Burden increases because of Program Change due to Agency Discretion: No

Burden Increase Due to:

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement:

Annual Cost to Federal Government: $11,934,520

Does this IC contain surveys, censuses, or employ statistical methods? No

Does this ICR request any personally identifiable information (see OMB Circular No. A-130 for an explanation of this term)? Please consult with your agency's privacy program when making this determination. Yes

Does this ICR include a form that requires a Privacy Act Statement (see 5 U.S.C. §552a(e)(3))? Please consult with your agency's privacy program when making this determination. Yes

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? No

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? No

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? No

Is this ICR related to the Pandemic Response? No

Agency Contact: Frances O'Donnell 703 405-2449 fran.odonnell@cathexiscorp.com

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