Foreign Medical Program Application and Claim Cover Sheet

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

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 2900-0648 can be found here:

Documents and Forms

Document Name Document Type
Form 10-7959f-2 Foreign Medical Program Application and Claim Cover Sheet Form
10-7959f-1 Foreign Medical Program (FMP) Registration Form vha-10-7959f-1-fill_2019_508.pdf Form
10-7959f-2 Foreign Medical Program (FMP) Claim Cover Sheet 10-7959f-2-fill_2019_508.pdf Form

Information Collection (IC) Details

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 17.35 38 CFR 17.125(d)

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	10-7959f-2	Foreign Medical Program (FMP) Claim Cover Sheet	10-7959f-2-fill_2019_508.pdf		Yes	Yes	Fillable Printable
Form	10-7959f-1	Foreign Medical Program (FMP) Registration Form	vha-10-7959f-1-fill_2019_508.pdf		Yes	No	Fillable Printable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records
Title: 54VA16 “Health Administration Center Foreign Medical Program Records – 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 %

	Requested	Change Due to Potential Violation of the PRA
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

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.