Signed enrollment application; see official instructions for signature requirements.
Health Eligibility Center
PO Box 5207
Janesville, WI 53547-5207
VA Form 10-10EZ — Apply for VA health care
Apply to enroll in VA health care. Family CHAMPVA coverage uses a different application.
Use the current official form
Revision: February 2025.
Only the methods summarized here were separately checked. Read the official PDF and program instructions for all methods, exceptions and required documents.
Submission instructions
Phone
Official enrollment application help.
877-222-8387
Official references
In person
Bring a signed enrollment application.
A VA medical center or clinic