White Paper

01-19-17

WHITE PAPER #2

DEPARTMENT OF VETERANS AFFAIRS

VA FORM 10-7959f-1 and 10-7959f-2 – FOREIGN MEDICAL PROGRAM FORM REVISIONS

ISSUE: A second revision of minor non-substantive changes were required to the content on VA
Form 10-7959f-1 and 10-7959f-2, which is used by Veterans with a service connected disability that are traveling or residing outside of the United States requesting reimbursement for medical care.

BACKGROUND: The Foreign Medical Program (FMP) is a Department of Veterans Affairs (VA) health care benefits program for Veterans with service-connected disabilities that are traveling or residing outside of the United States. FMP may furnish or reimburse hospital care and medical services in foreign countries to those eligible Veterans if necessary for treatment of a service-connected disability or any disability associated with and held to be aggravating a service-con­nected disability.

DISCUSSION: These two forms were OMB approved on 3/10/16. In the process of renewing the expiration some non-substantive changes were made and detailed in a White Paper (#1). The forms were submitted to 10B4 for posting to the VA Internet. They were sent to the 508 Compliance Section Office. Upon return to 10B4 the documents were sent back to us for review and the FMP Program Manager and the Policy Management Division wanted to make several additional non-substantive edits. Those edits are listed here. There is no change to the burden statement.

ACTIONS: The proposed changes make minor revisions. The overall burden to those completing the form is unchanged. A summary of the proposed changes are as follows:

Changes on both the Registration Form 10-7959f-1, and the Claim Form 10-7959-2

Location	Previous	Revised/Reason
1.) Front, top, address section, Website URL	CAPS on text within URL: “PURCHASED CARE”	Changed caps to lower case. URL is not case sensitive and caps are not a necessity. We don’t want to emphasize PURCHASEDCARE, as our new organization is now named: VHA Office of Community Care (VHA CC). We can’t change the URL but we can minimize to some extent. Same change happens on both forms to keep consistent message.
2.) Front, Veteran Information, Social Security Number (Required)	Social Security Number (Required)	Remove “(Required)” Program SME’s determined that it is not a requirement/condition to put down a Social Security number (see edit #3). Same change happens on both forms to keep consistent message.
3.) Back, Privacy Act statement, Disclosure:, third sentence	Added sentence: “Not supplying the SSN may delay processing your claims.”	Added sentence for clarification. Same change happens on both forms to keep consistent message.

Additional changes on Claim Form 10-7959f-2

Location	Previous	Revised/Reason
1.) Front, Section II, first sentence, billingstatement(s)	billingstatement(s)	Change to “billing statement(s)” Obvious spelling error. Separate two words with a space.
Location	Previous	Revised/Reason
2.) Front, Section II	Remove the word “basic” from  “… which must include the following basic information:”	Clarification. Basic implies that there are other items, which is not the case.
3.) Front, Section II, Listing of Provider and Claim Information	This section has a centered text layout	Changed the centering of text to read easier by listing the required items by numbering them and eliminating the centered text layout. Previously it was more difficult to identify the required items.
4.) Front, Section III, Bottom of section	Added a box with this statement: Attach a receipt of payment for each itemized billing statement(s) to process reimbursement and send payment to the Veteran or Provider.	Requested add by our legal department: Policy Management Division. Clarification on what needs to be sent in to process claim.
5.) Front, Section II, Bottom of section	Moved: “Payment to be sent to?” (check one) Veteran  Provider 	Moved the question and check boxes to the empty right hand bottom box and enlarged the text. We needed the room after listing the items in Section II and adding the “attach receipt…” text and box. And…now the text is easier to read. In addition, moved the check boxes to be in front of the words. More logical placement so one does not select the wrong one.
6.) Front, Section II, Under Claim Information	Remove the word “A” from …” A narrative description of each service” and add “and/or drug” to the #1 item under Claim information	Style edit / Clarification edit
7.) Front, Section II, Under Claim Information	Remove word “The” from “ The date(s) of service”	Style edit

IMPLICATIONS: Goal is to target these changes for approval as soon as possible to ensure if the need arises Office of General Counsel will have the necessary information. Immediate action is required as the FMP will be responsible for all Philippine claims processing.

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