Get Claim Cover Sheetforeign Medical Program (fmp) Va Health ...

The CLAIM COVER SHEET for the Foreign Medical Program (FMP) is a crucial form for obtaining reimbursement for medical services received outside the United States. This guide will walk you through each section of the form, providing clear instructions to ensure accurate completion and submission.

Follow the steps to fill out the CLAIM COVER SHEET for FMP online.

1. Click the ‘Get Form’ button to access the form and open it in the document editor.
2. In Section I - Veteran Information, provide your last name, first name, social security number, VA claim file number, and both physical and mailing addresses. Ensure accuracy in contact details such as your telephone number and email address.
3. Enter your date of birth in the format MM/DD/YYYY. This information is essential for verifying your identity.
4. Proceed to Section II - Diagnosis or Nature of Illness or Injury. Describe your diagnosis clearly, ensuring to include any relevant details about your condition.
5. In Section III - Claimant Certification, fill out the required information about the health care provider, including their full name, medical title, office address, and telephone number. If the billing address is different, please specify.
6. List all diagnosed conditions and provide a narrative description of each service rendered or drug prescribed. Include the billed charge for each service along with the corresponding date(s) of service.
7. Sign and date the form, certifying that the information and attachments provided are correct. Ensure that you have included an itemized billing statement from the provider along with any receipts as necessary for reimbursement.
8. Finally, select whether the payment should be sent to you, the Veteran, or the provider by checking the appropriate box.
9. After reviewing the completed form, save your changes. You can then download, print, or share the form as needed.

Complete your claim cover sheet online today for efficient processing of your reimbursement.