| INITIAL SECTION OF LETTER |
According to our records you have not responded to our previous requests
How Does This Affect Your Enrollment?
o We are unable to determine your priority for enrollment in the VA
health care system.
What Do You Need To Do?
o Complete a new VA Form 10-10EZR, Health Benefits Renewal Form, including
the financial section as soon as possible and return it to the
Business Office at the address above. You may obtain this form by
contacting our Business Office or by downloading the form from our
to complete the financial section of VA Form 10-10EZR, Health Benefits
website at: http://www.domain.ext/vaforms/search_action.asp
o Read the enclosed VA Form 4107VHA, Your Rights to Appeal Our Decision.
If you disagree with our decision, you or your representative may
complete a Notice of Disagreement and return it to the Enrollment
Coordinator or Health Benefits Advisor at your local VA health care
facility.
What If You Have Questions?
Renewal Form. This is to inform you that your current financial assessment
(means test) has expired.
How Does This Affect Your Eligibility for Cost Free Care?
o We do not have a current means test for you on file as is required to
determine your eligibility for either cost-free care or reduced
inpatient copayments.
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