source: FOIAVistA/tag/r/ENROLLMENT_APPLICATION_SYSTEM-EAS/EASEZP62.m@ 628

Last change on this file since 628 was 628, checked in by George Lilly, 14 years ago

initial load of FOIAVistA 6/30/08 version
File size: 7.2 KB
Line 
1EASEZP62 ;ALB/AMA - Print 1010EZ, Version 6 or greater, Cont., Page 2 ; 10/19/2000
2 ;;1.0;ENROLLMENT APPLICATION SYSTEM;**51,60**;Mar 15, 2001
3 ;
4 ;This routine copied from EASEZPF2; if the version # of the 1010EZ
5 ;application is 6.0 or greater, then this routine will be executed.
6 ;
7EN(EALNE,EAINFO) ; Entry point, called from EN^EASEZP6F
8 ; Input
9 ; EALNE - Array of line formats for output
10 ; EAINFO - Application Data array, see SETUP^EASEZP6F
11 ;
12 N EASD
13 ;
14 D HDR^EASEZP6F(.EALNE,.EAINFO)
15 S EASD=$NA(^TMP("EASEZ",$J,1))
16 ;
17 D II
18 D EI
19 D MIL
20 D PAP
21 ;
22 D FT^EASEZP6F(.EALNE,.EAINFO)
23 Q
24 ;
25II ; Print SECTION II - INSURANCE INFORMATION
26 ;
27 W !!?25,"SECTION II - INSURANCE INFORMATION (Use Separate Sheet for Additional Insurance)"
28 W ?131,$C(13) W:EALNE("ULC")="-" ! W EALNE("UL")
29 ;
30 W !,"1. ARE YOU COVERED BY HEALTH INSURANCE?",?49,"|2. HEALTH INSURANCE COMPANY NAME, ADDRESS AND TELEPHONE NUMBER"
31 W !?3,"(Including coverage through a spouse",?49,"| ",@EASD@("17A")
32 W !?3,"or another person) ",@EASD@(17),?49,"| "
33 W ?131,$C(13) W:EALNE("ULC")="-" ! W $E(EALNE("UL"),1,49)
34 ;
35 W !,"3. NAME OF POLICY HOLDER",?49,"| ",$P(@EASD@("17E"),U,2)
36 W !?3,@EASD@("17B"),?49,"| ",@EASD@("17I")
37 W ?131,$C(13) W:EALNE("ULC")="-" ! W EALNE("UL")
38 ;
39 W !,"4. POLICY NUMBER",?49,"|5. GROUP CODE",?85,"|6. ARE YOU ELIGIBLE FOR MEDICAID?"
40 W !?3,@EASD@("17C"),?49,"| ",@EASD@("17D"),?85,"|",?110,@EASD@("14J")
41 W ?131,$C(13) W:EALNE("ULC")="-" ! W EALNE("UL")
42 ;
43 W !,"7. ARE YOU ENROLLED IN MEDICARE HOSPITAL INSURANCE PART A? ",@EASD@("14K"),?75,"|7A. EFFECTIVE DATE (mm/dd/yyyy) ",@EASD@("14K1")
44 W ?131,$C(13) W:EALNE("ULC")="-" ! W EALNE("UL")
45 ;
46 W !,"8. ARE YOU ENROLLED IN MEDICARE HOSPITAL INSURANCE PART B? ",@EASD@("14L"),?75,"|8A. EFFECTIVE DATE (mm/dd/yyyy) ",@EASD@("14L1")
47 W ?131,$C(13) W:EALNE("ULC")="-" ! W EALNE("UL")
48 ;
49 W !,"9. NAME EXACTLY AS IT APPEARS ON YOUR MEDICARE CARD",?70,"|10. MEDICARE CLAIM NUMBER"
50 W !?3,@EASD@("14N"),?70,"| ",@EASD@("14M")
51 W ?131,$C(13) W:EALNE("ULC")="-" ! W EALNE("UL")
52 ;
53 W !,"11. IS NEED FOR CARE DUE TO ON THE JOB INJURY? ",@EASD@("22A"),?70,"|12. IS NEED FOR CARE DUE TO ACCIDENT? ",@EASD@("22B")
54 W ?131,$C(13) W:EALNE("ULC")="-" ! W EALNE("UL")
55 Q
56 ;
57EI ; Print SECTION III - EMPLOYMENT INFORMATION
58 ;
59 W !!?48,"SECTION III - EMPLOYMENT INFORMATION"
60 W ?131,$C(13) W:EALNE("ULC")="-" ! W EALNE("UL")
61 ;
62 W !,"1. VETERAN'S EMPLOYMENT STATUS",?47,"|1A. COMPANY NAME, ADDRESS AND TELEPHONE NUMBER"
63 W !?3,$P(@EASD@("15A"),U),?47,"| ",$P(@EASD@("15B"),U)," ",$P(@EASD@("15B"),U,4)
64 W !,"Date of retirement (mm/dd/yyyy) ",$P(@EASD@("15A"),U,2),?47,"| ",$P(@EASD@("15B"),U,2)
65 W !,"If employed or retired, complete item 1A",?47,"| ",$P(@EASD@("15B"),U,3)
66 W ?131,$C(13) W:EALNE("ULC")="-" ! W EALNE("UL")
67 ;
68 W !,"2. SPOUSE'S EMPLOYMENT STATUS",?47,"|2A. COMPANY NAME, ADDRESS AND TELEPHONE NUMBER"
69 W !?3,$P(@EASD@("16A"),U),?47,"| ",$P(@EASD@("16B"),U)," ",$P(@EASD@("16B"),U,4)
70 W !,"Date of retirement (mm/dd/yyyy) ",$P(@EASD@("16A"),U,2),?47,"| ",$P(@EASD@("16B"),U,2)
71 W !,"If employed or retired, complete item 2A",?47,"| ",$P(@EASD@("16B"),U,3)
72 W ?131,$C(13) W:EALNE("ULC")="-" ! W EALNE("UL")
73 Q
74 ;
75MIL ; Print out VA 10-10EZ Section IV, Military Service Information
76 ;
77 W !!?45,"SECTION IV - MILITARY SERVICE INFORMATION"
78 W ?131,$C(13) W:EALNE("ULC")="-" ! W EALNE("UL")
79 ;
80 W !,"1. LAST BRANCH OF SERVICE",?28,"|1A. LAST ENTRY DATE",?50,"|1B. LAST DISCHARGE DATE",?76,"|1C. DISCHARGE TYPE",?103,"|1D. MILITARY SERVICE NUMBER"
81 W !?4,@EASD@("13A"),?28,"| ",@EASD@("13B"),?50,"| ",@EASD@("13C"),?76,"| ",@EASD@("13D"),?103,"| ",@EASD@("13E")
82 W ?131,$C(13) W:EALNE("ULC")="-" ! W EALNE("UL")
83 ;
84 W !,"2. ANSWER YES OR NO:"
85 W ?131,$C(13) W:EALNE("ULC")="-" ! W EALNE("UL")
86 ;
87 W !," A. ARE YOU A PURPLE HEART AWARD RECIPIENT?",?58,"| ",@EASD@("14A1"),?64,"| F. WERE YOU EXPOSED TO ENVIRONMENTAL CONTAMINANTS WHILE",?124,"| ",@EASD@("14E")
88 W ?131,$C(13) W:EALNE("ULC")="-" ! W $E(EALNE("UL"),1,64)
89 ;
90 W !," B. ARE YOU A FORMER PRISONER OF WAR?",?58,"| ",@EASD@("14A2"),?64,"| SERVING IN SW ASIA DURING THE GULF WAR?",?124,"|"
91 W ?131,$C(13) W:EALNE("ULC")="-" ! W EALNE("UL")
92 ;
93 W !," C. DO YOU HAVE A VA SERVICE-CONNECTED RATING?",?58,"| ",@EASD@("14B"),?64,"| G. WERE YOU EXPOSED TO AGENT ORANGE WHILE SERVING IN",?124,"| ",@EASD@("14F")
94 W ?131,$C(13) W:EALNE("ULC")="-" ! W $E(EALNE("UL"),1,64)
95 ;
96 W !," C1. IF YES, WHAT IS YOUR RATED PERCENTAGE?",?58,"| ",@EASD@("14B1"),"%",?64,"| VIETNAM?",?124,"|"
97 W ?131,$C(13) W:EALNE("ULC")="-" ! W EALNE("UL")
98 ;
99 W !," D. DID YOU SERVE IN COMBAT AFTER 11/11/1998?",?58,"| ",@EASD@("14B2"),?64,"| H. WERE YOU EXPOSED TO RADIATION WHILE IN THE MILITARY?",?124,"| ",@EASD@("14G")
100 W ?131,$C(13) W:EALNE("ULC")="-" ! W EALNE("UL")
101 ;
102 W !," E. WAS YOUR DISCHARGE FROM MILITARY FOR A DISABILITY",?58,"| ",@EASD@("14D4"),?64,"| I. DID YOU RECEIVE NOSE & THROAT RADIUM TREATMENTS",?124,"| ",@EASD@("14G1")
103 W !?6,"INCURRED OR AGGRAVATED IN THE LINE OF DUTY?",?58,"| | WHILE IN THE MILITARY?",?124,"|"
104 W ?131,$C(13) W:EALNE("ULC")="-" ! W EALNE("UL")
105 ;
106 W !," E1. ARE YOU RECEIVING DISABILITY RETIREMENT PAY",?58,"| ",@EASD@("14D3"),?64,"| J. DO YOU HAVE A SPINAL CORD INJURY?",?124,"| ",@EASD@("14I")
107 W !?6,"INSTEAD OF VA COMPENSATION?",?58,"| |",?124,"|"
108 ;
109 W ?131,$C(13) W:EALNE("ULC")="-" ! W EALNE("UL")
110 Q
111 ;
112PAP ; Print SECTION V - PAPERWORK AND PRIVACY ACT INFORMATION
113 ;
114 W !!?34,"SECTION V - PAPERWORK REDUCTION ACT AND PRIVACY ACT INFORMATION"
115 W ?131,$C(13) W:EALNE("ULC")="-" ! W EALNE("UL")
116 ;
117 W !?5,"The Paperwork Reduction Act of 1995 requires us to notify you that this information collection is in accordance with the"
118 W !,"clearance requirements of section 3507 of the Paperwork Reduction Act of 1995. We may not conduct or sponsor, and you are not"
119 W !,"required to respond to, a collection of information unless it displays a valid OMB number. We anticipate that the time expended by"
120 W !,"all individuals who must complete this form will average 45 minutes. This includes the time it will take to read instructions,"
121 W !,"gather the necessary facts and fill out the form."
122 W !?5,"Privacy Act Information: VA is asking you to provide the information on this form under 38 U.S.C., sections 1705, 1710, 1712,"
123 W !,"and 1722 in order for VA to determine your eligibility for medical benefits. Information you supply may be verified through a"
124 W !,"computer-matching program. VA may disclose the information that you put on the form as permitted by law. VA may make a ""routine"
125 W !,"use"" disclosure of the information as outlined in the Privacy Act systems of records notices and in accordance with the VHA Notice"
126 W !,"of Privacy Practices. You do not have to provide the information to VA, but if you don't, VA may be unable to process your request"
127 W !,"and serve your medical needs. Failure to furnish the information will not have any affect on any other benefits to which you may"
128 W !,"be entitled. If you provide VA your Social Security Number, VA will use it to administer your VA benefits. VA may also use this"
129 W !,"information to identify veterans and persons claiming or receiving VA benefits and their records, and for other purposes authorized"
130 W !,"or required by law.",!
131 W ?131,$C(13) W:EALNE("ULC")="-" ! W EALNE("UL")
132 Q
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