10-7959f-2 Foreign Medical Program (FMP) Claim Cover Sheet

OMB Number: 2900-0648
Estimated burden: 11 minutes
Exp. Date: XX/XX/XXXX

Claim Cover Sheet – Foreign Medical Program (FMP)
Chief Business Office Purchased Care, 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: http://www.va.gov/PURCHASEDCARE/programs/veterans/fmp/
Instructions:
Using this form: Use this form to obtain reimbursement for medical services outside the United States (except the
Philippines). Attach itemized invoices or receipts.
Payments: Payment is based on the exchange rate on the date service was rendered.
Other Health Insurance (OHI): If other health insurance exists, attach the Explanation of Benefits (EOB) from the other
health insurance company and an itemized billing statement. Dates of service and provider charges on the EOB must
match billing statements.
Translation service: We will translate your claim.
Timely filing requirement: Claims must be received no later than two years from the date of service, or in case
of inpatient care, within two years from the date of discharge.
Section I - Veteran Information
VA Claim #
Veteran Name (Last Name, First Name, Middle Initial) (mandatory)

Mailing Address

Social Security #

(mandatory)

Date of Birth

(mm/dd/yyyy)

Telephone Number (include all prefixes international - country - city)

Email address

Section II - Diagnosis or Nature of Illness or Injury
All claim forms must be accompanied by the provider’s itemized billing
statement(s) which must include the following basic information:
Provider Information
Claim Information
Full name and medical title
Diagnoses treated
Office address
A narrative description of each service
Office telephone number
Each service’s billed charge
Billing address if different from office address
The date(s) of service
Payment to be sent to? (check one)

Veteran

Provider

Section III - Claimant Certification

Federal Laws (18 USC 287 and 1001) provide for criminal penalties for knowingly submitting or making false, fictitious, or fraudulent statements or claims.
I certify that the above information and attachments are correct and
represent actual services, dates, and fees charged.

VA FORM
Oct 2015

10-7959f-2

Signature (type if electronic)

Date

(retain this portion for your records)

Claim Cover Sheet for Foreign Medical Program (FMP)

Appendix

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. 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 11 minutes. This includes the time it will take to read instructions, gather the
necessary facts and fill out the form.

VA FORM
Oct 2015

10-7959f-2