Form 10-7959f-1 - Foreign Medical Program (Fmp) Registration Form - Department Of Veterans Affairs
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1OMB Approval Number 2900-0648
Estimated Burden Avg: 4 minutes
Expiration Date: 03/31/2019
Foreign Medical Program (FMP) Registration Form
Veterans can use this form to register in the VA Foreign Medical Program. The information provided on this form
will be used by VA to determine your eligibility for reimbursement for medical services outside the United
States. Please complete and submit to the FMP office at the address listed below or FAX to 1-303-331-7803.
All items must be completed (if not applicable, please write or type None or N/A).
Foreign Medical Program
PO Box 469061, Denver, CO 80246-9061 USA
Telephone number: 1-303-331-7590 | Fax number: 1-303-331-7803 | Email:
hac.fmp@va.gov
Website:
Veteran Information - Please Print
Veteran Last Name
Veteran First Name
MI
Social Security Number
VA Claim File Number
Date of Birth
Physical Address (Residence)
Mailing Address
Country
Country
Telephone Number
Email Address
Federal law provides criminal penalties, including a fine and/or imprisonment, for any materially false, fictitious,
or fraudulent statement or representation (See 18 U.S.C. 287 and 1001).
Veteran Signature
Date
(Required)
(Required)
I certify that the above information is correct and true to the best of my knowledge and belief.
If eligible, an FMP Benefits Authorization Letter will be
issued to you at your above mailing address.
Privacy Act and Paperwork Reduction Act Information: The information requested on this form is solicited under the Authority:
Title 38, U.S.C. 1724. The Systems of Records that apply are 23VA10NB3, Non-VA Care (Fee) Records-VA (FR 80 No.146 July 30,
2015) and 54VA10NB3, (FR 80 No. 41, Mar 3, 2015) "Veterans and Beneficiaries Purchased Care Community Health Care Claims,
Correspondence, Eligibility, Inquiry and Payment Files --VA''. Purpose: Records may be used to establish, determine, and monitor
eligibility to receive VA benefits and for authorizing and paying Non-VA healthcare services furnished to veterans and beneficiaries and
to process claims for medical care and services, and to process stipends. Principle: Veterans, Beneficiaries, Pensioned members of
the allied forces and Healthcare providers treating individuals who receive care under 38 U.S.C. Chapters 1 and 17. Routine Use:
Routine use disclosures are in accordance with the Privacy Act of 1974 (as amended) and the applicable system of records notice.
Disclosure: Your disclosure of the information requested on this form is voluntary. However, if the information including Social Security
number (SSN) (the SSN will be used to locate records) is not furnished completely and accurately, Department of Veterans Affairs will
be unable to comply with the request. Not supplying the SSN may delay processing your claims. VA may disclose the information as a
routine use disclosure outlined in applicable Privacy Act Systems of Records Notice. The Paperwork Reduction Act of 1995 requires
us to notify you that this information collection is in accordance with the clearance requirements of section 3507 of the Paperwork
Reduction Act of 1995. We may not conduct or sponsor and you are not required to respond to, a collection of information unless it
displays a valid OMB number. We anticipate that the time expended by all individuals who must complete this form will average 4
minutes. This includes the time it will take to read instructions, gather the necessary facts and fill out the form.
10-7959f-1
VA FORM
MAR 2016
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