How to Fill Out VA Form 10-10HS: Request for Hardship Determination

VA Form 10-10HS, the Request for Hardship Determination, is a one-page form you use to ask the VA to waive your hospital and outpatient medical copays after a drop in income or a spike in expenses. To fill it out, enter your personal information, check every hardship category that applies and write a short explanation of what changed, project your household income and deductible expenses for the current calendar year, sign it, and submit it to the business office at your nearest VA medical center.¹ If the VA approves, you are placed in Priority Group 5 and owe no medical copays from your filing date through December 31.

Before You Start

Pull your paperwork before you sit down with the form. You will be projecting numbers for the rest of the calendar year, and the reviewer wants to see the documents behind them. Gather recent pay stubs or a layoff letter, your prior year’s tax return as a baseline, itemized bills for unreimbursed medical expenses, and any receipts or paperwork tied to the hardship event itself: funeral costs, disaster repair estimates, a Social Security award letter, whatever fits your situation.

The form is short. What takes time is being accurate about the numbers and clear about what happened.

Filling Out the Form Section by Section

Personal Information

Fields 1 through 3F cover your full legal name, Social Security number, permanent address with the nine-digit ZIP code and county, and both your home and cell phone numbers. Do not leave the county blank. The VA matches your county against geographic income thresholds, and skipping it slows the review.¹

Reason for the Hardship Request

The form lists five hardship categories. Check every box that applies to you:

Reduction of household income (job loss, cut hours, retirement, disability onset)
Moved to a higher cost of living area
Paid out-of-pocket medical or dental expenses
Increase in number of dependents
Other (funeral costs, property damage from a disaster, or any other financial blow the first four don’t cover)

You don’t have to pick just one. Combining a smaller income drop with higher expenses often builds a stronger case than either fact would on its own.¹

Below the checkboxes is a space for a written explanation, and this is the part of the form that matters most. Numbers alone don’t tell the VA what happened to you. Write a plain factual account: what changed, when, and how it affects your ability to pay copays. If you lost a job, give the date and the income difference. If you had a medical emergency, state the total out-of-pocket cost. A few clear paragraphs beat a long narrative. The form directs you to “provide explanation, as needed, and attach documentation supporting your request.”¹

Projected Household Income

Report your projected gross household income for the current calendar year. The form defines household income as gross income from employment, net income from a farm or ranch, and other income including Social Security benefits, pension payments, and investment returns.¹ Include your spouse’s income where applicable.

Project realistically. If you were laid off in March, project the remaining months at your current income rate rather than annualizing what you earned in January and February. The whole point of the form is that this year won’t look like last year.

Deductible Expenses

List unreimbursed medical expenses you or your spouse have paid, funeral and burial costs, and education expenses for the veteran. Only include amounts not covered by insurance or another source. The VA subtracts these from your projected household income, and the adjusted number is what gets compared against the means test threshold for your area.¹

Signature and Date

Sign and date the form. A warning on the form notes that a false statement carries penalties including fines or imprisonment. Your projections don’t need to be exact to the penny, but they do need to be honest and supported by the documents you attach.

Documents to Attach

The form doesn’t publish a strict checklist, but the strength of your request depends on what you can prove. Attach copies, not originals:

Proof of the income change: a termination or layoff letter, a reduced-hours notice, a Social Security award letter, or recent pay stubs showing the drop
Your prior year’s tax return, so the VA has a baseline to compare against
Itemized statements for unreimbursed medical bills
Funeral or burial receipts, if you’re claiming those
Tuition invoices or payment records for the veteran’s own education
Any other paper trail for the hardship: insurance claims for property damage, a divorce decree affecting income, and so on

Organize the attachments in the same order as the sections on the form. It makes matching each claim to a document faster for the reviewer.

Where to Submit It

Submit the completed form by mail or in person to the business office or health administration office at your nearest VA medical center.² Find the address through the VA’s facility locator at va.gov/find-locations. There is no online submission option for Form 10-10HS.

Do not send it to the Health Eligibility Center in Janesville, Wisconsin. That address is for initial enrollment applications on Form 10-10EZ, not hardship requests.³

If you file in person, bring an extra copy of everything and ask the staff to date-stamp your copy. Your filing date matters: an approved exemption runs from the date of your request forward, not from whenever the VA finishes its review.¹

What the Waiver Covers

An approved hardship determination places you in Priority Group 5 and eliminates your hospital and outpatient medical copays through December 31 of the year you filed.⁴ Two limits to know before you file. Pharmacy copays are not included; you will still owe medication copays after approval.² And the exemption expires December 31. If your finances haven’t improved, you file a new 10-10HS in January.

The VA mails its decision. There is no published processing timeline for hardship requests, so if you have appointments coming up and are worried about being billed while the review is pending, call the business office at your medical center for a status check. Keep every piece of correspondence and watch your billing statements for charges that should have been paused.

If the VA Denies Your Request

The denial letter should explain the reasoning. The most common outcome is that projected income minus deductible expenses still comes in above the means test threshold for your area. If you documented expenses that weren’t counted, or if your finances changed again after you filed, you can ask for another look.

Form 20-0995, Decision Review Request: Supplemental Claim, lets you submit new or additional evidence for reconsideration of a VHA benefit decision.⁵ Form 20-0996 requests a higher-level review when you think the reviewer misapplied the rules to the evidence you already provided. Gather anything new that strengthens your case before you refile, and keep watching your bills while the review is pending; if a charge appears that a pending determination should cover, flag it with the business office rather than letting it sit.

This Form Does Not Erase Existing VA Debt

Form 10-10HS is forward-looking. It stops future copays for the rest of the calendar year. It does not wipe out copays you already owe.

For an existing balance, the tool is Form 5655, the Financial Status Report, which you use to request a waiver, negotiate a compromise, or set up a payment plan on debt already on the books.⁶ If you owe past-due copays and also can’t afford new ones, you may need both. Filing the 10-10HS first is usually the practical order: once new charges stop accruing, you can focus on the old balance.

1
U.S. Department of Veterans Affairs. VA Form 10-10HS – Request for Hardship Determination
2
Veterans Affairs. Request VA Financial Hardship Assistance
3
Veterans Affairs. How To Apply For VA Health Care
4
Veterans Affairs. VA Priority Groups
5
Department of Veterans Affairs. Decision Review Request: Supplemental Claim
6
U.S. Department of Veterans Affairs. Financial Status Report