Va Form 10 7959F 2 PDF Details

Access to healthcare services for veterans residing or traveling outside the United States is facilitated by the VA Foreign Medical Program (FMP) through a streamlined process embodied in the VA Form 10-7959F-2. The form serves as a crucial conduit for veterans seeking reimbursement for medical services received in foreign countries, ensuring that the financial burden of healthcare does not impede the well-being of individuals who have served their country. Detailed instructions within the form guide veterans through the submission process, which mandates the inclusion of itemized invoices or receipts to substantiate their claim. This process is not only designed to safeguard the financial interests of veterans but also underscores a commitment to transparency and accountability by requiring a certification that the information provided is accurate and true, under the potential penalty of law for any fraudulent claims. The form outlines specific provisions for payment, dictated by exchange rates at the time services were rendered, and addresses contingencies for those with other health insurance (OHI), mandating the attachment of an Explanation of Benefits (EOB). Furthermore, the form accommodates the need for translation services, ensuring no veteran is disadvantaged due to language barriers. The filing deadline, set at two years from the date of service or discharge in the case of inpatient care, emphasizes the importance of timely submission while recognizing the challenges that may accompany the collection of necessary documentation. Undergirded by federal law and regulations, including the authority of Title 38, U.S.C. 1724, and governed by privacy and paperwork reduction acts, the VA Form 10-7959F-2 exemplifies a structured yet flexible approach to administering benefits to veterans abroad, signifying the extended reach of the Department of Veterans Affairs’ commitment to its constituents, regardless of their geographic location.

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

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