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

OMB Number: 2900-0648

Est. Burden: 4 minutes
Exp. Date: xx/xx/xxxx

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
1-303-331-7803. 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

MI

Physical Address

Mailing Address

Country

Country

Telephone Number

Facsimile (FAX) Number

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 469061

Denver, CO

80246-9061

USA

(please retain this portion for your records)

Privacy Act and Paperwork Reduction Act Information: The information requested on this form is solicited
under the Authority: Title 38, U.S.C. 1724. The Systems of Records that apply are 23VA10NB3, Non-VA Care
(Fee) Records-VA (FR 80 No.146 July 30, 2015) and 54VA10NB3, (FR 80 No. 41, Mar 3, 2015) "Veterans and
Beneficiaries Purchased Care Community Health Care Claims, Correspondence, Eligibility, Inquiry and
Payment Files --VA''. Purpose: Records may be used to establish, determine, and monitor eligibility to receive
VA benefits and for authorizing and paying Non-VA healthcare services furnished to veterans and beneficiaries
and to process claims for medical care and services, and to process stipends. Principle: Veterans,
Beneficiaries, Pensioned members of the allied forces and Healthcare providers treating individuals who
receive care under 38 U.S.C. Chapters 1 and 17. Routine Use: Routine use disclosures are in accordance
with the Privacy Act of 1974 (as amended) and the applicable system of records notice. Disclosure: 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 applicable Privacy Act Systems of Records Notice.
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
Oct 2015

10-7959f-1