Free VA Form 10-7959f-1 - Foreign Medical Program (FMP) Registration Form - fill - Federal

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State: Federal
Category: Veterans Forms
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Download VA Form 10-7959f-1 - Foreign Medical Program (FMP) Registration Form - fill ( 416.8 kB)

Preview VA Form 10-7959f-1 - Foreign Medical Program (FMP) Registration Form - fill
OMB Number: 2900-0648

Est. Burden: 4 minutes

Foreign Medical Program (FMP) Registration Form
Please complete this form and submit it to the FMP office at the address listed below or by FAX to 1-303-331-7803. All items must be completed (if not applicable, please write or type None or N/A)

please print
Last Name US Social Security Number (SSN) Physical Address First Name VA Claim File Number Mailing Address MI

Telephone Number Veteran/Fiduciary signature (type if electronic)

Facsimile (FAX) Number Date

If eligible, an FMP Benefits Authorization Letter will be issued to you at your above mailing address. FMP Office PO Box 469061 Denver, CO 80246-9061 USA
(please retain this portion for your records)

Privacy Act and Paperwork Reduction Act Information: The information requested on this form is solicited under Title 38, U.S.C. The authority for collection of the requested information is 38 U.S.C. 1724. The form is used to register veterans with service-connected disabilities that are living or traveling overseas, into the Foreign Medical Program. 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. VA may disclose the information as a routine use disclosure outlined in the Privacy Act systems of records notices identified as 54VA16 "Health Administration Center Civilian Health and Medical Program Records VA" and in accordance with the VHA Notice of Privacy Practices, or as permitted by law. You do not have to provide the requested information but if any or all of the requested information is not provided, it may delay or result in denial of your request for FMP benefits. Failure to furnish the information will not have any effect on any other benefits to which you may be entitled. If you provide VA your Social Security Number, VA will use it to administer your VA benefits. VA may also use this information to identify veterans and persons claiming or receiving VA benefits and their records, and for other purposes authorized or required by law. 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 4 minutes. This includes the time it will take to read instructions, gather the necessary facts and fill out the form.