OMB Approval Number 2900-0648
Estimated Burden Avg: 11 minutes
Expiration Date: 03/31/2019
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: http://www.va.gov/purchasedcare/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)
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
Claim Information - Diagnoses treated:
1.) Narrative description of each service and/or drug
2.) Each service’s billed charge
3.) Date(s) of service
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).
Veteran Signature (Required) Date (Required)
I certify that the above information and attachments are correct
and represent actual services, dates, and fees charged.
Payment to be sent to?
(check one box)
Veteran Provider
VA FORM
MAR 2016
10-7959f-2
Veteran Last Name Veteran First Name MI
Social Security Number
VA Claim File Number
Physical Address (Residence)
Mailing Address
Country
Country
Telephone Number
Date of Birth
Email Address
Foreign Medical Program (FMP) Claim Cover Sheet
Attach a receipt of payment for each itemized billing
statement (s) to process reimbursement and send payment
to the Veteran or Provider.
