source: FOIAVistA/trunk/r/ENROLLMENT_APPLICATION_SYSTEM-EAS/EASEC103.m@ 1033

Last change on this file since 1033 was 628, checked in by George Lilly, 15 years ago

initial load of FOIAVistA 6/30/08 version

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1EASEC103 ;ALB/BRM,LBD - Print 1010EC LTC Enrollment form ; 9/7/01 9:49am
2 ;;1.0;ENROLLMENT APPLICATION SYSTEM;**5,7,40**;Mar 15, 2001
3 ;
4 ; Called from ^EASEC10E to print page 3 of the 1010EC
5 ;
6PAGE3(EALNE,EAINFO,EASDFN) ;Print page 3
7 N X,EASROOT
8 S EASROOT="^TMP(""1010EC"",$J,"_EASDFN_","
9 D HDR^EASEC10E(.EALNE,.EAINFO)
10 D SEC6
11 D SEC7
12 D SEC8
13 D FT^EASEC10E(.EALNE,.EAINFO)
14 Q
15 ;
16SEC6 ; print section 6 - Expenses
17 N EAS6
18 S EAS6=EASROOT_"6)"
19 ;
20 W !?55,"SECTION VI - EXPENSES",!,EALNE("D")
21 W !?54,"ITEMS",?113,"|",?119,"AMOUNT",?131,$C(13) X EAINFO("L")
22 W !,"1. Education (veteran, spouse or dependent)",?113,"| $",$J(@EAS6@(1),10,2),?131,$C(13) X EAINFO("L")
23 W !,"2. Funeral and Burial (spouse or child)",?113,"| $",$J(@EAS6@(2),10,2),?131,$C(13) X EAINFO("L")
24 W !,"3. Rent/Mortgage",?113,"| $",$J(@EAS6@(3),10,2),?131,$C(13) X EAINFO("L")
25 W !,"4. Utilities",?113,"| $",$J(@EAS6@(4),10,2),?131,$C(13) X EAINFO("L")
26 W !,"5. Car Payment Only (excludes gas, insurance, parking fees)",?113,"| $",$J(@EAS6@(5),10,2),?131,$C(13) X EAINFO("L")
27 W !,"6. Food",?113,"| $",$J(@EAS6@(6),10,2),?131,$C(13) X EAINFO("L")
28 W !,"7. Non-reimbursed medical expenses",?113,"| $",$J(@EAS6@(7),10,2),?131,$C(13) X EAINFO("L")
29 W !,"8. Court-ordered payments",?113,"| $",$J(@EAS6@(8),10,2),?131,$C(13) X EAINFO("L")
30 W !,"9. Insurance (exclude life insurance)",?113,"| $",$J(@EAS6@(9),10,2),?131,$C(13) X EAINFO("L")
31 W !,"10. Taxes (on any amount include in gross income, property, personal)",?113,"| $",$J(@EAS6@(10),10,2),?131,$C(13) X EAINFO("L")
32 W !,?95,"| TOTAL",?113,"| $",$J(@EAS6@(11),10,2),?131,$C(13) X EAINFO("L")
33 Q
34SEC7 ;print section 7 - Consent for Assignment of Benefits
35 N SECN
36 S SECN=$S($G(EAINFO("FORM")):"VIII",1:"VII") ;Added for LTC Phase IV
37 W !?42,"SECTION ",SECN," - CONSENT FOR ASSIGNMENT OF BENEFITS",!,EALNE("D")
38 W !,"I hereby authorize the Department of Veterans Affairs to disclose any such history, diagnostic and treatment information from my"
39 W !,"medical records to the contractor of any health plan contract under which I am apparently eligible for medical care or payment of"
40 W !,"the expense of care or to any other party against whom liability is asserted. I understand that I may revoke this authorization at"
41 W !,"any time, except to the extent that action has already been taken in reliance on it. Without my express revocation, this consent"
42 W !,"will automatically expire when all action arising from VA's claim for reimbursement from my medical care has been completed."
43 W !,"I authorize payment of medical benefits to VA for any services for which payment is accepted.",?131,$C(13) X EAINFO("L")
44 W !,"Signature",?100,"| Date",!?100,"|",?131,$C(13) X EAINFO("L")
45 Q
46SEC8 ;print section 8 - Consent and Agreement to make copayments
47 N I,WPLINE,EAS8,WPCNT,SECN
48 S EAS8=EASROOT_"8)",WPLINE=0,WPCNT=1
49 S SECN=$S($G(EAINFO("FORM")):"IX",1:"VIII") ; Added for LTC Phase IV
50 W !?39,"SECTION ",SECN," - CONSENT AND AGREEMENT TO MAKE COPAYMENTS",!,EALNE("D")
51 W !,"Completion of this form with signature of the Veteran or veteran's representative is certification that the veteran/representative"
52 W !,"has received a copy of the Privacy Act Statement and agrees to make appropriate copayments."
53 W !!,"I certify the foregoing statement(s) are true and correct to the best of my knowledge and belief and agree to make the applicable"
54 W !,"copayment for extended care services as required by law.",?131,$C(13) X EAINFO("L")
55 W !,"Signature",?100,"| Date",!?100,"|",?131,$C(13) X EAINFO("L")
56 Q:$G(EAINFO("FORM")) ;Added for LTC Phase IV (EAS*1*40)
57 W !,"Additional Comments:"
58 D:$D(EAS8)
59 .F S WPLINE=$O(@EAS8@(WPLINE)) Q:'WPLINE S WPCNT=WPCNT+1 W !,@EAS8@(WPLINE)
60 F I=WPCNT:1:14 W !
61 Q
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