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Foreign Medical Program Application and Claim Cover Sheet
Foreign Medical Program (FMP) Registration Form and Claim Cover Sheet
OMB: 2900-0648
IC ID: 28924
OMB.report
VA
OMB 2900-0648
ICR 202310-2900-003
IC 28924
( )
Documents and Forms
Document Name
Document Type
Form 10-7959f-1
Foreign Medical Program Application and Claim Cover Sheet
Form
10-7959f-1 Foreign Medical Program (FMP) Registration Form
VA Form 10-7959f-1.pdf
Form
10-7959f-1 Foreign Medical Program (FMP) Registration Form
VA Form 10-7959f-1.pdf
Form
10-7959f-2 Foreign Medical Program (FMP) Claim Cover Sheet
VA Form 10-7959f-2.pdf
Form
10-7959f-2 Foreign Medical Program (FMP) Claim Cover Sheet
VA Form 10-7959f-2.pdf
Form
Information Collection (IC) Details
View Information Collection (IC)
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-1
Foreign Medical Program (FMP) Registration Form
VA Form 10-7959f-1.pdf
Yes
No
Fillable Printable
Form
10-7959f-2
Foreign Medical Program (FMP) Claim Cover Sheet
VA Form 10-7959f-2.pdf
Yes
Yes
Fillable Printable
Federal Enterprise Architecture Business Reference Module
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 %
Approved
Program Change Due to New Statute
Program Change Due to Agency Discretion
Change Due to Adjustment in Agency Estimate
Change Due to Potential Violation of the PRA
Previously Approved
Annual Number of Responses for this IC
21,580
0
0
0
0
21,580
Annual IC Time Burden (Hours)
3,763
0
0
0
0
3,763
Annual IC Cost Burden (Dollars)
0
0
0
0
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.