VA Form 10-7959f-2, Foreign Medical Program (FMP) Claim Cover Sheet Instructions
This form contains 16 fields organized into 8 sections. Below is a complete list of every field, its type, and what information is expected.
| Field Name | Type | Description |
|---|---|---|
| Claimant Certification Date | ||
| Claimant Certification Date | Date |
Enter the date the claimant signed the certification confirming the information and attachments are correct and represent actual services, dates, and fees charged.
|
| Contact (Telephone and Email) | ||
| Telephone Number | Text |
Enter the veteran's primary telephone number for contact, including country and area code as appropriate (e.g., (999) 999-9999).
|
| Email Address | Text |
Enter the veteran's primary email address for contact and correspondence.
|
| General | ||
| SECTION 3 - 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). This is a Digital Signature field. Press Enter or Space bar to sign | Signature | |
| Mailing Address | ||
| Mailing Address | Text |
Enter the full mailing address where you receive mail for this claim (street address, apartment or unit number, city and postal code as applicable).
|
| Mailing Address — Country | Text |
Enter the country name for the mailing address shown above.
|
| Payment Destination (choose one) | ||
| Payment Destination: VETERAN | Radiobutton |
Check this box when you want the reimbursement/payment to be sent directly to the veteran (the patient).
|
| Payment Destination: PROVIDER | Radiobutton |
Check this box when you want the reimbursement/payment to be sent directly to the medical provider or facility that rendered the services.
|
| Physical Address (Residence) | ||
| Residence Street Address | Text |
Enter the veteran's full physical residence address (street number, street name, apartment or unit if applicable) as used for their primary home.
|
| Residence Country | Text |
Enter the country where the veteran's physical residence is located (e.g., United States, Canada).
|
| Veteran Identifiers (SSN, VA Claim #, DOB) | ||
| Social Security Number (SSN) | Text |
Enter the veteran's full Social Security Number exactly as shown on official records (include dashes if used).
|
| VA Claim File Number | Text |
Enter the veteran's VA claim/file number exactly as assigned by the VA or on related correspondence.
|
| Date of Birth | Date |
Enter the veteran's date of birth.
|
| Veteran Name | ||
| Veteran Last Name | Text |
Enter the veteran's family/last name exactly as it appears on official records.
|
| Veteran First Name | Text |
Enter the veteran's given/first name exactly as it appears on official records.
|
| Veteran Middle Initial | Text |
Enter the veteran's middle initial (single letter) or leave blank if none.
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