Monexor Medical Billing System

Patient Management

Name	DOB	SSN	Actions

Billing History

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End Date

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Invoice #	Date	Patient	Service	Amount	Status	Actions

Reports Dashboard

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📈 Revenue Trend (Last 30 Days of Selection)

👨‍⚕️ Revenue by Provider

Date	Invoice #	Patient	Service Summary	Amount

Accounts Receivable (AR) - Aging Report

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Total Outstanding

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Over 45 Days

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List of all invoices pending payment. Rows highlighted in red exceed 45 days since the sent date.

Invoice #	Patient	Service Date	Sent Date	Amount	Days Awaiting	Status

PROGRESS NOTE

Clinical Documentation

Company Information:

Patient:

DOB:

Gender:

SSN:

Visit Date:

Reason For Visit:

Attending Provider:

Referring Provider:

ICD-10-CM:

Notes:

Signature Image:

🔒 Provider Signature Area

CPT & Services Management

Code	Description	Price	Actions

📋 Tasks / To-Do List

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Task	Descripción / Anotación	Assignee	Fecha Límite	Priority	Status	Actions

📅 Appointment Management

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Date	Time	Patient	Service	Status	Actions

FMP Registration Form

Department of Veterans Affairs

Foreign Medical Program (FMP) Registration Form
OMB Approval Number 2900-0648
Estimated Burden Avg: 4 minutes

Veterans can use this form to register in the VA Foreign Medical Program. The information provided on this form will be used by VA to determine your eligibility for reimbursement for medical services outside the United States. Please complete and submit to the FMP office at the address listed below or FAX to 1-303-331-7803. All items must be completed (if not applicable, please write or type None or N/A).

Foreign Medical Program
PO Box 469061, Denver, CO 80246-9061 USA
Telephone number: 1-303-331-7590 | Fax number: 1-303-331-7803 | Email: hac.fmp@va.gov

Veteran Information - Please Print

Veteran Last Name

Veteran First Name / MI

Social Security Number

VA Claim File Number

Date of Birth (MM/DD/YYYY)

Physical Address (Residence)

Mailing Address

Country

Telephone Number

Email Address

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)

Date (Required)

I certify that the above information is correct and true to the best of my knowledge and belief.

If eligible, an FMP Benefits Authorization Letter will be issued to you at your above mailing address.

Privacy Act and Paperwork Reduction Act Information: The information requested on this form is solicited under the Authority: Title 38, U.S.C. 1724. The Systems of Records that apply are 23VA10NB3, Non-VA Care (Fee) Records-VA (FR 80 No.146 July 30, 2015) and 54VA10NB3, (FR 80 No. 41, Mar 3, 2015) "Veterans and Beneficiaries Purchased Care Community Health Care Claims, Correspondence, Eligibility, Inquiry and Payment Files --VA". Purpose: Records may be used to establish, determine, and monitor eligibility to receive VA benefits and for authorizing and paying Non-VA healthcare services furnished to veterans and beneficiaries and to process claims for medical care and services, and to process stipends.

FMP Claim Cover Sheet

Department of Veterans Affairs

FOREIGN MEDICAL PROGRAM (FMP) CLAIM COVER SHEET
OMB Control Number 2900-0648

Foreign Medical Program (FMP)
PO Box 200, Spring City, PA 19475
Telephone number: 1-833-930-0816 | Fax number: 1-303-331-7803
Email: hac.fmp@va.gov

Instructions:
Using this form: Use this form to obtain reimbursement for medical services outside the United States. Attach itemized invoices or receipts.

Payments: Payment is based on the exchange rate on the date service was rendered.

Timely filing requirement: Claims must be received no later than two years from the date of service.

SECTION I - VETERAN INFORMATION (Please Print)

Veteran Last Name

Veteran First Name / MI

Social Security Number

VA Claim File Number

Date of Birth (MM/DD/YYYY)

Physical Address (Residence)

Mailing Address

Country

Telephone Number

Email Address

SECTION II - DIAGNOSIS OR NATURE OF ILLNESS OR INJURY

All claim forms must be accompanied by the provider's itemized billing statement(s).

Provider Information:

Claim Information:

SECTION III - 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)

Date (Required) (MM/DD/YYYY)

I certify that the above information and attachments are correct and represent actual services, dates, and fees charged.

Attach a receipt of payment for each itemized billing statement(s) to process reimbursement and send payment to the Veteran or Provider.

PAYMENT TO BE SENT TO? (Check one box)
VETERAN PROVIDER

🔍

Select a patient and month, then click Search.

VETERANS OF PUERTO PLATA

PATIENT INFORMATION

INVOICE INFORMATION

VETERANS OF PUERTO PLATA

VETERANS OF PUERTO PLATA

PATIENT INFORMATION

INVOICE INFORMATION

Patient Management

Add New Patient

Patient Details

Billing History

Reports Dashboard

📈 Revenue Trend (Last 30 Days of Selection)

👨‍⚕️ Revenue by Provider

Accounts Receivable (AR) - Aging Report

PROGRESS NOTE

CPT & Services Management

Add New CPT Code

📋 Tasks / To-Do List

New Task

📅 Appointment Management

New Appointment

FMP Registration Form

FMP Claim Cover Sheet

📅 Monthly Summary — Services Completed