Va Form 10 7959F 1 PDF Details

Are you a veteran looking to claim back taxes? Do you need to obtain the correct forms for tax filing season? If so, then you may need information on Form 10-7959F-1 – an income tax form commonly used by veterans who have served in active military or combat duty. This article will provide an overview of Va Form 10 7959F 1, what it is and how to use it correctly. We’ll also go over tips on where to find expert help if needed and provide some guidance on navigating the complexities of this form. Read on for all the details!

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

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Stage no. 1 for completing va registration forms form

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