Foreign Medical Program Application and Claim Cover Sheet

Forms and Documents

Document Name	Status
Form 10-7959f-1 Foreign Medical Program Application and Claim Cover Sheet Form	Modified
122816 FMP White Paper #2 V3.docx Justification for No Material/Nonsubstantive Change	2017-02-22
2900-0648 justification 120415_Final_120815.doc Supporting Statement A	2015-12-31

IC Document Collections

IC ID	Document Title	Status
28924	Foreign Medical Program Application and Claim Cover Sheet Form	Modified

ICR Details

OMB Control No: 2900-0648	ICR Reference No: 201702-2900-011
Status: Historical Active	Previous ICR Reference No: 201507-2900-005
Agency/Subagency: VA	Agency Tracking No: 2900-0648
Title: Foreign Medical Program Application and Claim Cover Sheet
Type of Information Collection: No material or nonsubstantive change to a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 10/31/2018
	Date Received in OIRA: 10/11/2018
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	03/31/2019	03/31/2019	03/31/2019
Responses	21,580	0	21,580
Time Burden (Hours)	3,763	0	3,763
Cost Burden (Dollars)	0	0	0

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Abstract: Optional form used to determine appropriateness of payment for claims submitted for payment/reimbursement of medical expenses related to Veterans with a service-connected disability who are overseas (except for the Philippines).

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Authorizing Statute(s): None

Citations for New Statutory Requirements: None

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Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

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Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	80 FR 46104	08/03/2015
30-day Notice:	Federal Register Citation:	Citation Date:
	80 FR 77083	12/11/2015
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 1

IC Title	Form No.	Form Name
Foreign Medical Program Application and Claim Cover Sheet	10-7959f-2, 10-7959f-1	Foreign Medical Program (FMP) Registration Form ,   Foreign Medical Program (FMP) Claim Cover Sheet

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ICR Summary of Burden

	Total Approved	Previously Approved	Change Due to New Statute	Change Due to Agency Discretion	Change Due to Adjustment in Estimate	Change Due to Potential Violation of the PRA
Annual Number of Responses	21,580	21,580	0	0	0	0
Annual Time Burden (Hours)	3,763	3,763	0	0	0	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

Burden increases because of Program Change due to Agency Discretion: No

Burden Increase Due to:

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement:

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Annual Cost to Federal Government: $34,815

Does this IC contain surveys, censuses, or employ statistical methods? No

Does this ICR request any personally identifiable information (see OMB Circular No. A-130 for an explanation of this term)? Please consult with your agency's privacy program when making this determination.     Yes

Does this ICR include a form that requires a Privacy Act Statement (see 5 U.S.C. §552a(e)(3))? Please consult with your agency's privacy program when making this determination.     Yes

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? No

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? No

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? No

Is this ICR related to the Pandemic Response? Uncollected

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Common Form ICR:  No

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On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).

The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:

(a) It is necessary for the proper performance of agency functions;

(b) It avoids unnecessary duplication;

(c) It reduces burden on small entities;

(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;

(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;

(f) It indicates the retention periods for recordkeeping requirements;

(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:

(i) Why the information is being collected;

(ii) Use of information;

(iii) Burden estimate;

(iv) Nature of response (voluntary, required for a benefit, or mandatory);

(v) Nature and extent of confidentiality; and

(vi) Need to display currently valid OMB control number;

(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.

(i) It uses effective and efficient statistical survey methodology (if applicable); and

(j) It makes appropriate use of information technology.

If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.

Certification Date: 10/11/2018

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