Foreign Medical Program (FMP) Registration Form and Claim Cover Sheet

ICR 201911-2900-005

OMB: 2900-0648

Federal Form Document

IC Document Collections
ICR Details
2900-0648 201911-2900-005
Received in OIRA 201702-2900-011
VA 2900-0648
Foreign Medical Program (FMP) Registration Form and Claim Cover Sheet
Reinstatement without change of a previously approved collection   No
Regular 11/20/2020
  Requested Previously Approved
36 Months From Approved
21,580 0
3,763 0
0 0

Foreign Medical Program (FMP) is a federal health benefits program for Veterans administered by the Department of Veterans Affairs (VA) Veterans Health Administration (VHA). FMP is a Fee for Service (indemnity plan) program and provides reimbursement for VA adjudicated service-connected conditions. Title 38 CFR 17.35 states that the VA will provide coverage for the Veteran’s service-connected disability when the Veteran is residing or traveling overseas. VA Form 10-7959f-1, Foreign Medical Program (FMP) Registration Form, is used to register into the Foreign Medical Program those Veterans with service-connected disabilities that are living or traveling overseas. Title 38 CFR 17.125(c) states that requests for consideration of claim reimbursement from approved health care providers and Veterans are to be mailed to VHA Health Administration Center. VA Form 10-7959f-2, Foreign Medical Program Claim Cover Sheet, streamlines the claims submission process for claimants or physicians while also reducing the time spent by VA on processing FMP claims. The cover sheet will allow foreign providers and Veterans a better understanding of basic information required for the processing and payment of claims.

None
None

Not associated with rulemaking

  85 FR 23603 04/28/2020
85 FR 73596 11/18/2020
No

1
IC Title Form No. Form Name
Foreign Medical Program Application and Claim Cover Sheet 10-7959f-2, 10-7959f-1 Foreign Medical Program (FMP) Claim Cover Sheet ,   Foreign Medical Program (FMP) Registration Form

  Total Request Previously Approved Change Due to New Statute Change Due to Agency Discretion Change Due to Adjustment in Estimate Change Due to Potential Violation of the PRA
Annual Number of Responses 21,580 0 0 0 0 21,580
Annual Time Burden (Hours) 3,763 0 0 0 0 3,763
Annual Cost Burden (Dollars) 0 0 0 0 0 0
No
No

$38,655
No
    Yes
    Yes
No
No
No
No
Frances O'Donnell 703 405-2449 fran.odonnell@cathexiscorp.com

  No

On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).
The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:
 
 
 
 
 
 
 
    (i) Why the information is being collected;
    (ii) Use of information;
    (iii) Burden estimate;
    (iv) Nature of response (voluntary, required for a benefit, or mandatory);
    (v) Nature and extent of confidentiality; and
    (vi) Need to display currently valid OMB control number;
 
 
 
If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.
11/20/2020


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