Va Form 10 7959F 2 PDF Details

Navigating bureaucracy can be tricky but understanding the ins and outs of the VA Form 10-7959F-2 is essential for staying informed about your VA disability status. With so much paperwork to sift through, it’s important to have a clear grasp on what this particular form means and how it could affect you as well as an appreciation for just how critical its role in your VA benefits application process is. Read on for a detailed look into the subject - from why it matters to a step-by-step guide that will help you understand exactly what this form implies!

QuestionAnswer
Form NameVa Form 10 7959F 2
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other namesva fmp, form claim, va form fillable 10 7959f 2, claim cover

Form Preview Example

OMB Approval Number 2900-0648

Estimated Burden Avg: 11 minutes

Expiration Date: 01/31/2024

Foreign Medical Program (FMP) Claim Cover Sheet

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/

Instructions:

Using this form: Use this form to obtain reimbursement for medical services outside the United States. Attach itemized invoices or receipts.

Payments: Payment is based on the exchange rate on the date service was rendered.

Other Health Insurance (OHI): If other health insurance exists, attach the Explanation of Benefits (EOB) from the other health insurance company and an itemized billing statement. Dates of service and provider charges on the EOB must match billing statements.

Translation service: We will translate your claim.

Timely filing requirement: Claims must be received no later than two years from the date of service, or in case of inpatient care, within two years from the date of discharge.

Section I - 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

 

 

 

 

Section II - Diagnosis or

Nature of Illness or Injury

All claim forms must be accompanied by the provider’s itemized billing statement(s) which must include the following information:

Section III - Claimant Certification

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).

Provider Information:

1.) Full name and medical title

2.) Office address

3.) Office telephone number

4.) Billing address if different from office address

Veteran Signature (Required) (Sign in ink)

Date (Required) (MM/DD/YYYY)

Claim Information - Diagnoses treated:

1.) Narrative description of each service and/or drug

2.) Each service’s billed charge

3.) Date(s) of service

I certify that the above information and attachments are correct

and represent actual services, dates, and fees charged.

Attach a receipt of payment for each itemized billing statement (s) to process reimbursement and send payment to the Veteran or Provider.

Payment to be sent to?

 

Veteran

 

Provider

 

 

(check one box)

 

 

 

 

 

 

VA FORM

10-7959f-2

Page 1

JUN 2021

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 11 minutes. This includes the time it will take to read instructions, gather the necessary facts and fill out the form.

VA FORM 10-7959f-2, JUN 2021

Page 2

How to Edit Va Form 10 7959F 2 Online for Free

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Step 2: As soon as you start the editor, you'll see the document all set to be filled in. Aside from filling out different blanks, you may as well perform many other actions with the file, namely putting on custom text, editing the initial textual content, inserting graphics, putting your signature on the PDF, and much more.

When it comes to blank fields of this specific PDF, here is what you should consider:

1. Begin completing your va form claim cover sheet with a group of necessary blank fields. Note all the necessary information and ensure not a single thing forgotten!

Part # 1 in filling in va fmp claim form

2. Just after this part is completed, go to type in the applicable details in all these - Claim Information Diagnoses, Attach a receipt of payment for, Payment to be sent to check one box, Veteran, Provider, VA FORM JUN f, and Page.

Filling in segment 2 in va fmp claim form

When it comes to VA FORM JUN f and Payment to be sent to check one box, make sure that you double-check them here. Both of these could be the most important ones in this form.

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