source: FOIAVistA/trunk/r/ENROLLMENT_APPLICATION_SYSTEM-EAS/EASEZP63.m@ 1397

Last change on this file since 1397 was 628, checked in by George Lilly, 15 years ago

initial load of FOIAVistA 6/30/08 version
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1EASEZP63 ; ALB/AMA - Print 1010EZ, Version 6 or greater, Cont. ; 10/25/2000
2 ;;1.0;ENROLLMENT APPLICATION SYSTEM;**51,60,57**;Mar 15, 2001
3 ;
4 ;This routine copied from EASEZPF3; if the version # of the 1010EZ
5 ;application is 6.0 or greater, then this routine will be executed.
6 ;
7EN(EALNE,EAINFO,EASDG) ; Entry point to print Page 3, called from EN^EASEZP6F
8 ; Input
9 ; EALNE - Array of line formats for output
10 ; EAINFO - Application Data array, see SETUP^EASEZRPF
11 ; EASDG - Flag variable to signify request to print from DG options
12 ;
13 N EASIGN
14 ;
15 I $$GET1^DIQ(712,EAINFO("EASAPP")_",",4)]"" D
16 . S EASIGN=$$GET1^DIQ(712,EAINFO("EASAPP")_",",4.1)
17 S EASIGN=$G(EASIGN)
18 ;
19 D HDR^EASEZP6F(.EALNE,.EAINFO)
20 S EASD=$NA(^TMP("EASEZ",$J,2))
21 ;
22 D FIN
23 D DEP
24 D INC
25 D EXP
26 D FT^EASEZP6F(.EALNE,.EAINFO)
27 ;
28 Q
29 ;
30FIN ; Print out VA 10-10EZ Section VI, Financial Disclosure information
31 ;
32 W !!?50,"SECTION VI - FINANCIAL DISCLOSURE"
33 W ?131,$C(13) W:EALNE("ULC")="-" ! W EALNE("UL")
34 ;
35 W !,"Failure to disclose your previous year's financial information may affect your eligibility for health care benefits. Your financial"
36 W !,"information is used by VA to accurately determine if you should be responsible for copayments for office visits, pharmacy,"
37 W !,"inpatient, nursing home and long term care, and for some veterans, priority for enrollment. You are not required to provide this"
38 W !,"information. However, completing the financial dislosure section results in a more accurate determination of your eligibility for"
39 W !,"health care services/benefits."
40 ;
41 N EAN,EAY S (EAY,EAN)="___"
42 ;IF NO ENTRY, THEN NO MEANS TEST, SO NO ANSWER
43 ;IF @EASD@(998)="Y", THEN VET DECLINES TO GIVE INFO, SO ANSWER "NO"
44 I $D(@EASD@(998)) D
45 . S:@EASD@(998)="YES" EAN=" X "
46 . S:@EASD@(998)="NO" EAY=" X "
47 ;
48 W !!?3,EAN," NO, I DO NOT WISH TO PROVIDE INFORMATION IN SECTIONS VII THROUGH X. I understand that VA is currently not enrolling veterans"
49 W !,"who decline to provide financial information unless other special eligibility factors exist. However, if I am enrolled, I agree to"
50 W !,"pay the applicable VA copayments. (Sign and date the application in Section XII.)"
51 ;
52 W !!?3,EAY," YES, I WILL PROVIDE SPECIFIC INCOME AND/OR ASSET INFORMATION TO ESTABLISH MY ELIGIBILITY FOR CARE. (Complete all sections"
53 W !,"below that apply to you with last calendar year's information. Sign and date the application in Section XII.)"
54 W !?131,$C(13) W:EALNE("ULC")="-" ! W EALNE("UL")
55 Q
56 ;
57DEP ; Print out VA 10-10EZ Section VII, Dependent Information
58 ;
59 W !!?24,"SECTION VII - DEPENDENT INFORMATION (Use a separate sheet for additional dependents)"
60 W ?131,$C(13) W:EALNE("ULC")="-" ! W EALNE("UL")
61 ;
62 W !,"1. SPOUSE'S NAME (Last, First, Middle Name)",?60,"|2. CHILD'S NAME (Last, First, Middle Name)"
63 W !?4,$P(@EASD@(1),U),?60,"| ",@EASD@(2)
64 W ?131,$C(13) W:EALNE("ULC")="-" ! W EALNE("UL")
65 ;
66 W !,"1A. SPOUSE'S MAIDEN NAME",?60,"|2A. CHILD'S RELATIONSHIP TO YOU"
67 W !?4,$P(@EASD@(1),U,2),?60,"| ",@EASD@(9)
68 W ?131,$C(13) W:EALNE("ULC")="-" ! W EALNE("UL")
69 ;
70 W !,"1B. SPOUSE'S SOCIAL SECURITY NUMBER",?60,"|2B. CHILD'S SOCIAL SECURITY NUMBER",?99,"|2C. DATE CHILD BECAME YOUR"
71 W !?4,@EASD@(3),?60,"| ",@EASD@(7),?99,"| DEPENDENT ",@EASD@(11)
72 W ?131,$C(13) W:EALNE("ULC")="-" ! W EALNE("UL")
73 ;
74 W !,"1C. SPOUSE'S DATE OF BIRTH (mm/dd/yyyy)",?44,"|1D. DATE OF MARRIAGE (mm/dd/yyyy)",?84,"|2D. CHILD'S DATE OF BIRTH (mm/dd/yyyy)"
75 W !?4,@EASD@(4),?44,"| ",@EASD@(10),?84,"| ",@EASD@(5)
76 W ?131,$C(13) W:EALNE("ULC")="-" ! W EALNE("UL")
77 ;
78 W !,"1E. SPOUSE'S ADDRESS AND TELEPHONE NUMBER (Street, City, State, ZIP)",?84,"|2E. WAS CHILD PREMANENTLY AND TOTALLY"
79 W !?4,$P(@EASD@(6),U),?84,"| DISABLED BEFORE THE AGE OF 18? ",@EASD@(14)
80 W ?131,$C(13) W:EALNE("ULC")="-" ! N Z F Z=1:1:85 W " "
81 W $E(EALNE("UL"),1,47)
82 ;
83 W !?4,$P(@EASD@(6),U,2),?84,"|2F. IF CHILD IS BETWEEN 18 AND 23 YEARS"
84 W !?4,@EASD@(8),?84,"| OF AGE, DID CHILD ATTEND SCHOOL LAST"
85 W !?84,"| CALENDAR YEAR? ",@EASD@(15)
86 W ?131,$C(13) W:EALNE("ULC")="-" ! W EALNE("UL")
87 ;
88 W !,"3. IF YOUR SPOUSE OR DEPENDENT CHILD DID NOT LIVE WITH YOU LAST",?65,"|2G. EXPENSES PAID BY YOUR DEPENDENT CHILD FOR COLLEGE, VOCATIONAL"
89 W !?3,"YEAR, ENTER THE AMOUNT YOU CONTRIBUTED TO THEIR SUPPORT",?65,"| REHABILITATION OR TRAINING (e.g., tuition, books, materials)"
90 W !?6,"SPOUSE $ ",$P(@EASD@(12),U),?35,"CHILD $ ",$P(@EASD@(12),U,2),?65,"|",?73,"$ ",@EASD@(13)
91 W ?131,$C(13) W:EALNE("ULC")="-" ! W EALNE("UL")
92 Q
93 ;
94INC ; Print out VA 10-10EZ Section VIII, Gross Annual Income information
95 ;
96 I $G(EASDG),+@EASD@(999) W !!?6,"SECTION VIII - PREVIOUS CALENDAR YEAR GROSS ANNUAL INCOME OF VETERAN, SPOUSE AND DEPENDENT CHILDREN (INCOME YEAR: ",@EASD@(999),")"
97 E W !!?17,"SECTION VIII - PREVIOUS CALENDAR YEAR GROSS ANNUAL INCOME OF VETERAN, SPOUSE AND DEPENDENT CHILDREN"
98 W !?30,"(Use a separate sheet for additional dependents' financial information)"
99 W ?131,$C(13) W:EALNE("ULC")="-" ! W EALNE("UL")
100 ;
101 W !?76,"VETERAN",?97,"SPOUSE",?117,"CHILD 1"
102 W ?131,$C(13) W:EALNE("ULC")="-" ! W EALNE("UL")
103 ;
104 W !,"1. GROSS ANNUAL INCOME FROM EMPLOYMENT (wages, bonuses, tips, etc.)",?69,"| $ ",$P(@EASD@("2C1"),U),?90,"| $ ",$P(@EASD@("2C1"),U,2),?110,"| $ ",$P(@EASD@("2C1"),U,3)
105 W !,"EXCLUDING INCOME FROM YOUR FARM, RANCH, PROPERTY OR BUSINESS",?69,"|",?90,"|",?110,"|"
106 W ?131,$C(13) W:EALNE("ULC")="-" ! W EALNE("UL")
107 ;
108 W !,"2. NET INCOME FROM YOUR FARM, RANCH, PROPERTY OR BUSINESS",?69,"| $ ",$P(@EASD@("2C3"),U),?90,"| $ ",$P(@EASD@("2C3"),U,2),?110,"| $ ",$P(@EASD@("2C3"),U,3)
109 W ?131,$C(13) W:EALNE("ULC")="-" ! W EALNE("UL")
110 ;
111 W !,"3. LIST OTHER INCOME AMOUNTS (Social Security, compensation,",?69,"| $ ",$P(@EASD@("2C2"),U),?90,"| $ ",$P(@EASD@("2C2"),U,2),?110,"| $ ",$P(@EASD@("2C2"),U,3)
112 W !,"pension, interest, dividends. Exclude welfare)",?69,"|",?90,"|",?110,"|"
113 W ?131,$C(13) W:EALNE("ULC")="-" ! W EALNE("UL")
114 Q
115 ;
116EXP ; Print out VA 10-10EZ Section IX, Deductible Expense Information
117 ;
118 I $G(EASDG),+@EASD@(999) W !!?27,"SECTION IX - PREVIOUS CALENDAR YEAR DEDUCTIBLE EXPENSES (INCOME YEAR: ",@EASD@(999),")"
119 E W !!?38,"SECTION IX - PREVIOUS CALENDAR YEAR DEDUCTIBLE EXPENSES"
120 W ?131,$C(13) W:EALNE("ULC")="-" ! W EALNE("UL")
121 ;
122 W !,"1. TOTAL NON-REIMBURSED MEDICAL EXPENSES PAID BY YOU OR YOUR SPOUSE (e.g., payments for doctors, dentists,",?110,"| $ ",@EASD@("2D1")
123 W !,"medications, Medicare, health insurance, hospital and nursing home) VA will calculate a deductible and the",?110,"|"
124 W !,"net medical expenses you may claim.",?110,"|"
125 W ?131,$C(13) W:EALNE("ULC")="-" ! W EALNE("UL")
126 ;
127 W !,"2. AMOUNT YOU PAID LAST CALENDAR YEAR FOR FUNERAL AND BURIAL EXPENSES FOR YOUR DECEASED SPOUSE OR DEPENDENT",?110,"| $ ",@EASD@("2D2")
128 W !,"CHILD (Also enter spouse or child's information in Section VII.)",?110,"|"
129 W ?131,$C(13) W:EALNE("ULC")="-" ! W EALNE("UL")
130 ;
131 W !,"3. AMOUNT YOU PAID LAST CALENDAR YEAR FOR YOUR COLLEGE OR VOCATIONAL EDUCATIONAL EXPENSES (e.g., tuition,",?110,"| $ ",@EASD@("2D3")
132 W !,"books, fees, materials) DO NOT LIST YOUR DEPENDENT'S EDUCATIONAL EXPENSES",?110,"|"
133 W ?131,$C(13) W:EALNE("ULC")="-" ! W EALNE("UL")
134 Q
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