Va Form 10 7959F 1 PDF Details

Veterans seeking medical services outside the United States can find an essential resource in the VA 10 7959f-1 form, known as the Foreign Medical Program (FMP) Registration Form. This document plays a crucial role in the process of registering for the FMP, thereby enabling veterans to receive reimbursement for overseas medical services deemed necessary. With an emphasis on the collection of accurate and comprehensive personal and medical information, the form outlines the relevant details that the Veterans Affairs (VA) requires to ascertain a veteran's eligibility. A meticulous completion of this form is vital, as it directly impacts the effectiveness and efficiency of the VA's evaluation process. Upon submission, the delivered information undergoes a thorough review, after which eligible veterans are dispatched an FMP Benefits Authorization Letter. The form encompasses sections for veteran personal information, including but not limited to, name, Social Security number, VA claim file number, and contact details, all structured to streamline the eligibility determination. The implications for incomplete or inaccurately provided information are significant, potentially delaying or even inhibiting the processing of claims. Moreover, the act of submitting the form involves a legal attestation to the veracity of the furnished details, under penalty of law for any fraudulent representations. This underscores the form's importance not only as a procedural necessity but also as a legal document underpinning the integrity of the claims process. Consequently, understanding the VA 10 7959f-1 form is imperative for veterans seeking to leverage the FMP for medical care abroad, ensuring that they are well-informed and adequately prepared for the nuances of the application process.

QuestionAnswer
Form NameVa Form 10 7959F 1
Form Length1 pages
Fillable?No
Fillable fields0
Avg. time to fill out15 sec
Other namesva foreign program, va foreign medical create, va form 10 7959f 1, va foreign medical

Form Preview Example

OMB Approval Number 2900-0648

Estimated Burden Avg: 4 minutes

Expiration Date: 01/31/2024

Foreign Medical Program (FMP) Registration Form

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 below or FAX to 1-303-331-7803.

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

MI

Social Security Number

VA Claim File Number

Date of Birth (MM/DD/YYYY)

Physical Address (Residence)

Mailing Address

Country

 

Country

 

 

 

 

 

Telephone Number

Email Address

 

 

 

 

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.

If eligible, an FMP Benefits Authorization Letter will be

issued to you at your above mailing address.

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. Not supplying the SSN may delay processing your claims. 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 4 minutes. This includes the time it will take to read instructions, gather the necessary facts and fill out the form.

VA FORM

10-7959f-1

JUN 2021

How to Edit Va Form 10 7959F 1 Online for Free

You could fill out form program fmp easily with our online editor for PDFs. Our editor is continually evolving to provide the very best user experience achievable, and that's thanks to our dedication to continual enhancement and listening closely to user comments. To start your journey, take these easy steps:

Step 1: Click the "Get Form" button in the top area of this webpage to access our PDF tool.

Step 2: As soon as you launch the tool, you will notice the form made ready to be filled in. Besides filling out various blank fields, you might also perform some other things with the PDF, namely adding any textual content, modifying the initial text, adding images, putting your signature on the document, and more.

This PDF form needs some specific information; in order to ensure accuracy and reliability, remember to take into account the recommendations directly below:

1. Complete your form program fmp with a selection of essential blanks. Get all of the required information and be sure absolutely nothing is forgotten!

Stage no. 1 for completing va registration forms form

Step 3: Be certain that your information is accurate and then click on "Done" to proceed further. Join FormsPal right now and immediately gain access to form program fmp, set for download. Every last change made is conveniently preserved , letting you edit the form later when necessary. At FormsPal.com, we aim to ensure that all your information is stored secure.

Va Form 10 7959F 1 isn’t the one you’re looking for?

Related Documents