VA Form 10-7959f-2 Claim Cover Sheet - Foreign Medical Program (FMP)

OMB Number: 2900-0648
Estimated burden: 11 minutes

CLAIM COVER SHEET – FOREIGN MEDICAL PROGRAM (FMP)

VA Health Administration Center
Foreign Medical Program, PO Box 469061, Denver, CO 80246-9061 USA
Telephone number: 1-303-331-7590
Email address: [email protected]

Fax number: 1-303-331-7803
Website address: www.va.gov/hac

INSTRUCTIONS:
Using this form: Use this form to obtain reimbursement for medical services outside the United States (except the
Philippines). Attach itemized invoices or receipts.
Payments: Payment is based on the exchange rate on the date service was rendered.
Other Health Insurance (OHI): If other health insurance exists, attach the Explanation of Benefits (EOB) from the other
health insurance company and an itemized billing statement. Dates of service and provider charges on the EOB must
match billing statements.
Translation Service: We will translate your claim.
Timely filing requirement: Claims must be received no later than two years from the date of service, or in case
of inpatient care, within two years from the date of discharge.

Veteran Name (Last Name, First Name, Middle Initial)

SECTION I
VETERAN INFORMATION
(mandatory)
VA Claim #
Social Security #

Mailing Address

(mandatory)

Date of Birth

(mm/dd/yyyy)

Telephone Number (include all prefixes international - country - city)

Email address

SECTION II
DIAGNOSIS OR NATURE OF ILLNESS OR INJURY
All claim forms must be accompanied by the provider’s itemized billing
statement(s) which must include the following basic information:
Provider Information
Full name and medical title
Office address
Office telephone number
Billing address if different from office address

PAYMENT TO BE SENT TO? (check one)
VA FORM
NOV 2008

10-7959f-2

VETERAN

Claim Information
Diagnoses treated
A narrative description of each service
Each service’s billed charge
The date(s) of service

PROVIDER

(retain this portion for your records)

Claim Cover Sheet for Foreign Medical Program (FMP)

Appendix

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 process each claim for foreign medical services submitted by the veteran for payment. 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 11 minutes. This includes the
time it will take to read instructions, gather the necessary facts and fill out the form.

VA FORM
NOV 2008

10-7959f-2