VA Form 10-7959f-2: Foreign Medical Program (FMP) Claim Cover Sheet

VA Form 10-7959f-2 PDF Details

All claim forms must be accompanied by the provider's itemized billing statement(s).

Timely filing: 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.

Provider information: full name and medical title, office address, office telephone number and billing address if different from office address.

Claim information: narrative description of each service and/or drug, each service's billed change and date(s) of service.

OHI: if a claim has been submitted to OHI, attach the Explanation of Benefits (EOB) from the other health insurance company and an itemized billing statement.

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