Information Collection

Foreign Medical Program Application and Claim Cover Sheet

IC 28924 under ICR 201702-2900-011 · 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⚠️ Notice: This information collection may be referencing outdated material.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

Documents and forms in this information collection
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_012317.pdf	Form
10-7959f-2 Foreign Medical Program (FMP) Claim Cover Sheet 10-7959f-2-fill_012317.pdf	Form

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 17.125(d) 38 CFR 17.35

Information Collection Instruments:

table that charts list of 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_012317.pdf		Yes	No	Fillable Printable
Form	10-7959f-2	Foreign Medical Program (FMP) Claim Cover Sheet	10-7959f-2-fill_012317.pdf		Yes	Yes	Fillable Printable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records

Title: 54VA16 âHealth Administration Center Foreign Medical Program Records â VA

FR Citation: 68 FR 53784

Number of Respondents: 3,320

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Previously Approved
Annual Number of Responses for this IC	21,580	21,580
Annual IC Time Burden (Hours)	3,763	3,763
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
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.