VA 10-10EZR PDF Template

[toc] The United States Department of Veteran Affairs uses a great deal of different paperwork. All of this paperwork serves a particular purpose and is important. One of the forms is the Health Benefits Update Form. It’s used to allow nurses to file an application for recognition by the Veterans Health Administration.

Nurse anesthetists and nurses need to receive recognition by the Veterans Health Administration before they can bill VA health insurance for their services. If a nurse wants to be able to treat a veteran by using their VA health insurance, they need to fill out this form and submit it to the Department of Veterans Affairs.

There’s a great deal of detailed information that the form requires regarding the medical professional. All of it must be filled out to gain approval. The most important part of the information is about an applicant’s qualifications. After the information is submitted, it’s the job of the Department of Veteran Affairs to verify that the information is correct.

This 4-page VA form is meant to be used by nurse anesthetists and nurses who wish to treat veterans with VA insurance. Until they receive the VA’s approval, they won’t be able to bill VA insurance for their services. For many veterans, VA health insurance is the most important aspect of their healthcare. Nurses don’t want to be deprived of the opportunity to treat veterans just because they haven’t yet received clearance to do so.

This form was first issued in 2004, and its last revision occurred in 2016. Any time a nurse anesthetist or other nursing professional wishes to treat veterans with VA insurance, they need to receive authorization before they do so. It’s important to try to become recognized with the VA as soon as possible. This broadens the scope of patients that a nurse can treat, while also broadening the patients’ nursing options.

Nursing professionals who fail to use this form will not receive VA clearance, authorization, or recognition. This means they will not be able to bill VA health insurance. If they treat a veteran with VA health insurance, that veteran would need to pay the entire cost out-of-pocket. Because of how expensive medical treatment is, this isn’t a viable scenario for anyone.

In the first few boxes, you’ll be required to give basic personal information. Fill out your full name, present address, date of birth, and place of birth. You’ll need to give two telephone numbers, one for your residence and one for your business. You’ll also need to check whether the application is for a general practice or specialty practice.

In Box 8, you’ll need to indicate your citizenship status. For applicants who aren’t United States citizens, you’ll need to check which country you are a citizen in. In Box 9, you’ll detail any previous applications for VA appointment. You’ll need to give a convenient time for your present employer to be contacted in Box 10, while Box 11 reflects the date you’re available to begin your new employment.

If you were part of active military duty, make note of this in Box 12. In Box 13, you’ll need to note every state you’ve ever received a nursing registration in, along with your registration number and its expiration date.

Boxes 15 through 18 will have you check yes or no questions. If any question asks you to explain on a separate sheet, do so, and attach the sheet to your application. Ignore Boxes 19 and 20, as these will be filled out by the designee or facility director.

Part V is where you’ll note details about your current professional liability insurance carrier. You’ll need to indicate the date the coverage began, the name of your prior carrier, and whether any carrier has ever refused to renew your insurance.

In Part VI, you’ll explain your nursing qualifications. Write the name of each school you went to in order to receive your basic nursing education. Indicate the address of the school, the length of the program, the date the program was completed, and any degrees or diplomas received. The “Additional Education” portion should be used for any school that wasn’t directly related to basic nursing.

Part VII is the nursing experience section, in which you’ll explain all of your previous employment. In Part VII, you’ll give general information about yourself.

Part IX is where you’ll list your references. You need at least four, and they cannot be related to you by marriage or blood. They must have been able to judge your professionalism at some point over the last five years.

For Boxes 30 through 39, you’ll need to answer yes or no questions. If your answer to any of the questions is “Yes,” you’ll need to explain this answer on a separate sheet of paper. Finally, Part X requires your signature along with the date.

The last page is your authorization for release of information. You’ll need to check the boxes indicating that you authorize this release before the VA can verify your background.[pdf-embedder url=”https://cdn-prod-pdfsimpli-wpcontent.azureedge.net/pdfseoforms/pdf-20180219t134432z-001/pdf/va-form-10-10ezr.pdf?sv=2018-03-28&si=readpolicy&sr=c&sig=MXHnWmn0sXNXztiU%2Bugk2d7DV7KBCOuXF3oBMx0EeEw%3D”]