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Agency Information Collection Activities (Foreign Medical Program) Under OMB Review

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In compliance with the Paperwork Reduction Act (PRA) of 1995 (44 U.S.C. 3501-3521), this notice announces that the Veterans Health Administration (VHA), Department of Veterans Affairs, will submit the collection of information abstracted below to the Office of Management and Budget (OMB) for review and comment. The PRA submission describes the nature of the information collection and its expected cost and burden and includes the actual data collection instrument.


Comments must be submitted on or before November 19, 2012.


Submit written comments on the collection of information through; or to VA's OMB Desk Officer, OMB Human Resources and Housing Branch, New Executive Office Building, Room 10235, Washington, DC 20503 (202) 395-7316. Please refer to “OMB Control No. 2900-0648” in any correspondence.


Crystal Rennie, Enterprise Records Service (005R1B), Department of Veterans Affairs, 810 Vermont Avenue NW., Washington, DC 20420, (202) 632-7492, fax (202) 632-7583 or email Please refer to “OMB Control No. 2900-0648.”



a. Foreign Medical Program (FMP) Registration Form, VA Form 10-7959f-1

b. Claim Cover Sheet—Foreign Medical Program (FMP), VA Form 10-7959f-2.

OMB Control Number: 2900-0648.

Type of Review: Extension of a currently approve collection.


a. Veterans with service connected disabilities living or traveling overseas complete VA Form 10-7959f-1 to enroll in the Foreign Medical Program.

b. Healthcare providers complete VA Form 10-7959f-2 to submit claims for payments or reimbursement of expenses relating to veterans living or traveling overseas (except for the Philippines) with service-connected disability. VA will accept provider's generated billing statement, Uniform Billing—Forms (UB) 04, and Medicare Health Insurance Claims Form, CMS 1500 for payments or reimbursements.

An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a currently valid OMB control number. The Federal Register Notice with a 60-day comment period soliciting comments on this collection of information was published on August 1, 2012 at pages 45716-45717.

Affected Public: Individuals or households.

Estimated Total Annual Burden:

a. Foreign Medical Program, VA Form 10-7959f-1—111 hours.

b. Claim Cover Sheet, VA Form 10-7959f-2—3,652 hours.

Estimated Average Burden per Respondent:

a. Foreign Medical Program, VA Form 10-7959f-1-4 minutes.

b. Claim Cover Sheet, VA Form 10-7959f-2-11 minutes.

Frequency of Response: On occasion.

Estimated Number of Respondents:

a. Foreign Medical Program, VA Form 10-7959f-1-1,660.

b. Claim Cover Sheet, VA Form 10-7959f-2-19,920.

Dated: October 15, 2012.

By direction of the Secretary.

William F. Russo,

Deputy Director, Office of Regulations Policy and Management, Office of the General Counsel, Department of Veterans Affairs.

[FR Doc. 2012-25754 Filed 10-18-12; 8:45 am]