10-7959f-1 Foreign Medical Program (FMP) Registration Form

OMB Number: 2900-0648

Department of Veterans Affairs

Est. Burden: 4 minutes

Foreign Medical Program (FMP) Registration Form

Please complete this form and submit it to the FMP office at the address listed below or by FAX to
303-331-7803. All items must be completed (if not applicable, please write or type None or N/A)

please print
Last Name

First Name

US Social Security Number (SSN)

VA Claim File Number

Physical Address

Mailing Address

Country

Country

Telephone Number

Facsimile (FAX) Number

MI

Veteran/Fiduciary signature (type if electronic)

Date

If eligible, an FMP Benefits Authorization Letter will be
issued to you at your above mailing address.
FMP Office

PO Box 65021

Denver, CO

80206-9021

USA

(please retain this portion for your records)

Privacy Act and Paperwork Reduction Act Information: The information requested on this form is solicited
under Title 38, U.S.C. The authority for collection of the requested information is 38 U.S.C. 1724. The form is
used to register veterans with service-connected disabilities that are living or traveling overseas, into the
Foreign Medical Program. Your disclosure of the information requested on this form is voluntary. However, if
the information including Social Security Number (SSN) (the SSN will be used to locate records) is not
furnished completely and accurately, Department of Veterans Affairs will be unable to comply with the request.
VA may disclose the information as a routine use disclosure outlined in the Privacy Act systems of records
notices identified as 54VA16 “Health Administration Center Civilian Health and Medical Program Records VA” and in accordance with the VHA Notice of Privacy Practices, or as permitted by law. You do not have to
provide the requested information but if any or all of the requested information is not provided, it may delay or
result in denial of your request for FMP benefits. Failure to furnish the information will not have any effect on
any other benefits to which you may be entitled. If you provide VA your Social Security Number, VA will use it
to administer your VA benefits. VA may also use this information to identify veterans and persons claiming or
receiving VA benefits and their records, and for other purposes authorized or required by law. The Paperwork
Reduction Act of 1995 requires us to notify you that this information collection is in accordance with the
clearance requirements of section 3507 of the Paperwork Reduction Act of 1995. We may not conduct or
sponsor and you are not required to respond to, a collection of information unless it displays a valid OMB
number. We anticipate that the time expended by all individuals who must complete this form will average 4
minutes. This includes the time it will take to read instructions, gather the necessary facts and fill out the form.
VA FORM
Month Year

10-7959f-1