10-7959f-1 Foreign Medical Program (FMP) Registration Form

OMB Approval Number 2900-0648
Estimated Burden Avg: 4 Minutes
Expration Date: 01/31/2024

Foreign Medical Program (FMP) Registration Form
PAPERWORK REDUCTION ACT AND PRIVACY ACT INFORMATION
PAPERWORK REDUCTION ACT: This information collection is in accordance with the clearance requirements of Section 3507 of the Paperwork Reduction Act of 1995.
Public reporting burden for this collection of information is estimated to average 4 minutes per response, including the time for reviewing instructions, searching existing
data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Comments regarding this burden estimate or any
other aspect of this collection, including suggestions for reducing the burden, may be addressed by calling the customer service center at 1-877-466-7124. Respondents
should be aware that notwithstanding any other provision of law, no person shall be subject to any penalty for failing to comply with a collection of information if it does
not display a current, valid OMB control number. The purpose of this data collection is to provide a mechanism for the creation of fraud, waste and abuse complaint inquiry
cases for VHA programs.
PRIVACY ACT STATEMENT: The authority for collection of the requested information on this form is in accordance with the Department of Veteran Affairs System of
Records Notice: 23VA10NB3, Non-VA Care (Fee) Records-VA (FR: Thursday, July 30, 2015) and 54VA10NB3, Veterans and Beneficiaries Purchased Care Community Health
Care Claims, Correspondence, Eligibility, Inquiry and Payment Files --VA (FR: Tuesday March 3, 2015). Purpose: The purpose of collecting this information is to adjudicate
and process fraud, waste and abuse cases for VHA programs. Routine Use: Disclosure to other Federal agencies may be made to assist such agencies in preventing and
detecting possible fraud or abuse by individuals in their operations and programs. You do not have to provide the requested information, but if any or all the requested
information is not provided it may significantly delay processing of your request. Failure to furnish the requested information will have no adverse impact on any other VA
benefit to which you may be entitled. VA System of Records Notices are available Online via The Office of the Federal Register at http://www.ofr.gov/.

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 or FAX to 1-303-331-7803 or EMAIL to hac.fmp@va.gov.
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: https://www.va.gov/communitycare/programs/veterans/fmp/
Veteran Information - Please Print
Veteran Last Name

Veteran First Name

Social Security Number

VA Claim File Number

Physical Address (Residence)

Mailing Address

Country

Country

Telephone Number

Email Address

MI
Date of Birth (MM/DD/YYYY)

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 (Required)(Sign in ink)

Date (Required) (MM/DD/YYYY)

I certify that the above information is correct and true to the best of my knowledge and belief.
VA FORM
JUN 2021

10-7959f-1