Information Collection

Foreign Medical Program Application and Claim Cover Sheet

IC 28924 under ICR 201507-2900-005 · OMB 2900-0648.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 2900-0648 can be found here:

Documents and Forms

Document Name Document Type
Form 10-7959f-1 Foreign Medical Program Application and Claim Cover Sheet Form
10-7959f-1 Foreign Medical Program (FMP) Registration Form vha-10-7959f-1-fill_2015.pdf Form
10-7959f-2 Foreign Medical Program (FMP) Claim Cover Sheet vha-10-7959f-2-fill_2015.pdf Form

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Foreign Medical Program Application and Claim Cover Sheet	Agency IC Tracking Number:	2900-0648

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Voluntary

CFR Citation: 38 CFR 17.35 38 CFR 17.125(d)

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	10-7959f-1	Foreign Medical Program (FMP) Registration Form	vha-10-7959f-1-fill_2015.pdf		Yes	No	Fillable Printable
Form	10-7959f-2	Foreign Medical Program (FMP) Claim Cover Sheet	vha-10-7959f-2-fill_2015.pdf		Yes	Yes	Fillable Printable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 3,320	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	21,580	0	21,580
Annual IC Time Burden (Hours)	3,763	1	3,762
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

Title	Document	Date Uploaded
No associated records found

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.