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.
We will translate your claim.
Timely filing requirement:
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:
Payment is based on the exchange rate on the date service was rendered.
Other Health Insurance (OHI):
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:
Use this form to obtain reimbursement for medical services outside the United States. Attach itemized
invoices or receipts.
Payments:
Section I - Veteran Information (Please Print)
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:
Provider Information:
1.) Full name and medical title
2.) Office address
3.) Office telephone number
4.) Billing address if different from office address
1.) Narrative description of each service and/or drug
2.) Each service’s billed charge
3.) Date(s) of service
Claim Information - Diagnoses treated:
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).
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?
(check one box)
Veteran Provider
VA FORM
JUN 2021
10-7959f-2
Using this form:
Veteran Last Name Veteran First Name MI
Social Security Number VA Claim File Number
Date of Birth (MM/DD/YYYY)
Physical Address (Residence)
Country
Mailing Address
Country
Telephone Number Email Address
Date (Required)
(MM/DD/YYYY)
Veteran Signature (Required) (Sign in ink)
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