| 1 | DGMTP4 ;ALB/RMO,CAW,LD - Print Means Test 10-10F Cont. ;16 APR 1992 2:35 pm
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| 2 | ;;5.3;Registration;**33,182,300**;Aug 13, 1993
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| 3 | ;
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| 4 | EN ;Entry point to print signature block and special notes
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| 5 | ; Set category, status and type of care variables from means test file.
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| 6 | ; These are initially set in DGMTP with the call to SET^DGMTSCU2, but
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| 7 | ; are calculated by the data available. For this portion of the
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| 8 | ; printout they should be set to the means test file entry.
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| 9 | N DGCAT,DGMTS,DGTYC,X
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| 10 | S DGMTS=$P(DGMT0,"^",3),DGCAT=$P($$MTS^DGMTU(DFN,$S(DGMTS=2:6,1:DGMTS)),"^",2),DGTYC=$P($G(^DG(408.32,DGMTS,0)),"^",3)
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| 11 | D SIG,NOTE
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| 12 | Q Q
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| 13 | ;
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| 14 | SIG ;Print signature block
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| 15 | W $$UL^DGMTSCU1(DGUL,DGLNE1),!?30,"Completion of this form with signature of veteran is certification",!?30,"that the veteran has received a copy of the privacy act statement."
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| 16 | W $$UL^DGMTSCU1(DGUL,DGLNE1),!?1,"THE ABOVE INFORMATION IS CORRECT",?63,"| Signature of Veteran or Designee",?109,"| Date",!?1,"TO THE BEST OF MY KNOWLEDGE.",?63,"|",?109,"|"
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| 17 | W $$UL^DGMTSCU1(DGUL,DGLNE1),!,?37,"F. TO BE COMPLETED BY DISCRETIONARY VETERANS WHO",!,?41,"ARE REQUIRED TO MAKE COPAYMENTS"
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| 18 | W $$UL^DGMTSCU1(DGUL,DGLNE1),!?1,"Eligibility Category",?30,"| Veterans in Category C must agree to pay VA a Deductible not to exceed the Medicare"
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| 19 | W !?30,"| Deductible plus a per diem for Hospital and Nursing Home care. A per Visit",!
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| 20 | W:DGMTYPT=1 ?11,DGCAT
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| 21 | W ?30,"| Deductible is required for Category C Veterans to receive Outpatient care."
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| 22 | W !?30,"| The Billing Period and Rates are specified in 38 U.S.C."
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| 23 | W $$UL^DGMTSCU1(DGUL,DGLNE1),!?1,"I AGREE TO PAY THE VA THE APPLICABLE",?63,"| Signature of Veteran or Designee",?109,"| Date"
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| 24 | W !?1,"DEDUCTIBLE FOR MY MEDICAL CARE.",?63,"| ",$S(DGTYC'="D":"NOT APPLICABLE",'$P(DGMT0,"^",11):"HAS NOT AGREED",1:""),?109,"|"
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| 25 | Q
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| 26 | ;
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| 27 | NOTE ;Print any special notes
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| 28 | W !,DGLNE,!?1,"Special Note(s):"
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| 29 | S X=+$P(DGMT0,"^",23) I (X>1) W ?30,"This means test was administered by the ",$S(X<4:"IVM",1:$$SR^DGMTAUD1(DGMT0,DGMTI)_" Medical")," Center.",!
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| 30 | I DGMTS=2 W ?30,"Patient's means test is Pending Adjudication.",!
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| 31 | I DGMTS=3 W ?30,"Patient's means test is No Longer Required.",!
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| 32 | I $P(DGMT0,"^",14),DGMTS=6 W ?30,"Patient has declined to provide income information.",!
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| 33 | I $P(DGMT0,"^",16) W ?30,"Previous years thresholds were used to determine the patient's eligibility for care.",!?30,"The means test must be re-applied once the correct thresholds are available.",!
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| 34 | I $P(DGMT0,"^",4)'=DGINT W ?30,"Patient's annual income does not match the income associated with the means test." W:DGTYC'="N" !?30,"Please edit and complete the means test again.",!
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| 35 | I $P(DGMT0,"^",19)=2 W ?30,"Copay Exemption Test Status is: "_$S($P(DGMT0,U,3)=7:"EXEMPT",$P(DGMT0,U,3)=8:"NON-EXEMPT",$P(DGMT0,U,3)=9:"INCOMPLETE",$P(DGMT0,U,3)=10:"NO LONGER APPLICABLE",$P(DGMT0,U,3)=11:"PENDING ADJUDICATION",1:"")
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| 36 | W ! S DGPGE=2 D FT^DGMTP ;end of second page of form
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| 37 | Q
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