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Federal forms, ICRs, and supporting documents

Information Collection

Foreign Medical Program Application and Claim Cover Sheet

IC 28924 under ICR 202310-2900-003 · OMB 2900-0648.

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Foreign Medical Program Application and Claim Cover Sheet 2900-0648
 
No Modified
 
Voluntary
 
38 CFR 17.35 38 CFR 17.125(d)

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 VA Form 10-7959f-1.pdf Yes No Fillable Printable
Form 10-7959f-2 Foreign Medical Program (FMP) Claim Cover Sheet VA Form 10-7959f-2.pdf Yes Yes Fillable Printable

Health Public Health Monitoring

54VA16 “Health Administration Center Foreign Medical Program Records – VA  68 FR 53784

3,320 0
   
Individuals or Households
 
   0 %

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

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