Foreign Medical Program (FMP) Registration Form and Claim Cover Sheet

Forms and Documents

Document Name	Status
Form 10-7959f-2 Foreign Medical Program Application and Claim Cover Sheet Form	Modified
30-day FRN_FMP Registration Form & Claim Cover Sheet_11182020.pdf Supplementary Document	2020-11-18
60-day FRN_FMP Registration Form & Claim Cover Sheet_04282020.pdf Supplementary Document	2020-11-12
Supp Stmt A_2900-0648_FMP Regis Form & Claim Cover Sheet_revised Nov 2020.docx Supporting Statement A	2020-11-18

IC Document Collections

IC ID	Document Title	Status
28924	Foreign Medical Program Application and Claim Cover Sheet Form	Modified

ICR Details

OMB Control No: 2900-0648	ICR Reference No: 201911-2900-005
Status: Received in OIRA	Previous ICR Reference No: 201702-2900-011
Agency/Subagency: VA	Agency Tracking No: 2900-0648
Title: Foreign Medical Program (FMP) Registration Form and Claim Cover Sheet
Type of Information Collection: Reinstatement without change of a previously approved collection	Common Form ICR:  No
Type of Review Request: Regular	Date Submitted to OIRA: 11/20/2020

	Requested	Previously Approved
Expiration Date	36 Months From Approved
Responses	21,580	0
Time Burden (Hours)	3,763	0
Cost Burden (Dollars)	0	0

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Abstract: Foreign Medical Program (FMP) is a federal health benefits program for Veterans administered by the Department of Veterans Affairs (VA) Veterans Health Administration (VHA). FMP is a Fee for Service (indemnity plan) program and provides reimbursement for VA adjudicated service-connected conditions. Title 38 CFR 17.35 states that the VA will provide coverage for the Veteran’s service-connected disability when the Veteran is residing or traveling overseas. VA Form 10-7959f-1, Foreign Medical Program (FMP) Registration Form, is used to register into the Foreign Medical Program those Veterans with service-connected disabilities that are living or traveling overseas. Title 38 CFR 17.125(c) states that requests for consideration of claim reimbursement from approved health care providers and Veterans are to be mailed to VHA Health Administration Center. VA Form 10-7959f-2, Foreign Medical Program Claim Cover Sheet, streamlines the claims submission process for claimants or physicians while also reducing the time spent by VA on processing FMP claims. The cover sheet will allow foreign providers and Veterans a better understanding of basic information required for the processing and payment of claims.

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Authorizing Statute(s): None

Citations for New Statutory Requirements: None

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Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

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Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	85 FR 23603	04/28/2020
30-day Notice:	Federal Register Citation:	Citation Date:
	85 FR 73596	11/18/2020
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 1

IC Title	Form No.	Form Name
Foreign Medical Program Application and Claim Cover Sheet	10-7959f-2, 10-7959f-1	Foreign Medical Program (FMP) Claim Cover Sheet ,   Foreign Medical Program (FMP) Registration Form

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ICR Summary of Burden

	Total Request	Previously Approved	Change Due to New Statute	Change Due to Agency Discretion	Change Due to Adjustment in Estimate	Change Due to Potential Violation of the PRA
Annual Number of Responses	21,580	0	0	0	0	21,580
Annual Time Burden (Hours)	3,763	0	0	0	0	3,763
Annual Cost Burden (Dollars)	0	0	0	0	0	0

Burden increases because of Program Change due to Agency Discretion: No

Burden Increase Due to:

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement:

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Annual Cost to Federal Government: $38,655

Does this IC contain surveys, censuses, or employ statistical methods? No

Does this ICR request any personally identifiable information (see OMB Circular No. A-130 for an explanation of this term)? Please consult with your agency's privacy program when making this determination.     Yes

Does this ICR include a form that requires a Privacy Act Statement (see 5 U.S.C. §552a(e)(3))? Please consult with your agency's privacy program when making this determination.     Yes

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? No

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? No

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? No

Is this ICR related to the Pandemic Response? No

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Common Form ICR:  No

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On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).

The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:

(a) It is necessary for the proper performance of agency functions;

(b) It avoids unnecessary duplication;

(c) It reduces burden on small entities;

(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;

(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;

(f) It indicates the retention periods for recordkeeping requirements;

(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:

(i) Why the information is being collected;

(ii) Use of information;

(iii) Burden estimate;

(iv) Nature of response (voluntary, required for a benefit, or mandatory);

(v) Nature and extent of confidentiality; and

(vi) Need to display currently valid OMB control number;

(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.

(i) It uses effective and efficient statistical survey methodology (if applicable); and

(j) It makes appropriate use of information technology.

If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.

Certification Date: 11/20/2020

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