source: FOIAVistA/trunk/r/ENROLLMENT_APPLICATION_SYSTEM-EAS/EASEZPF1.m@ 1671

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1EASEZPF1 ;ALB/SCK - Print 1010EZ Cont. ; 10/19/2000
2 ;;1.0;ENROLLMENT APPLICATION SYSTEM;;Mar 15, 2001
3 ;
4EN(EALNE,EAINFO) ; Main entry point for VA 10-10EZ page 1
5 N X,EASD
6 ;
7 S EASD="^TMP(""EASEZ"",$J,1)"
8 D HDRMAIN^EASEZPF(.EALNE)
9 D DEM
10 D EXP
11 D EMP
12 D INS
13 D NOK
14 ;
15 D FT^EASEZPF(.EALNE,.EAINFO)
16 S EAINFO("VET")=@EASD@(2),EAINFO("SSN")=@EASD@(5)
17 Q
18 ;
19DEM ; Print VA 10-10 Section I, Demographic information
20 ;
21 W !,"1A. Type of Benefits Applied For: ",@EASD@("1A")
22 W ?131,$C(13) W:EALNE("ULC")="-" ! W EALNE("UL")
23 ;
24 W !,"1B. If Applying For Health Services, Which VA Medical Center or Outpatient Clinic Do You Prefer "
25 W !?5,@EASD@("1B")
26 W ?131,$C(13) W:EALNE("ULC")="-" ! W EALNE("UL")
27 ;
28 W !,"2. Veteran's Name",?60,"|3. Other Names Used",?110,"|4. Gender"
29 W !?3,@EASD@(2),?60,"| ",@EASD@(3),?110,"| ",@EASD@(4)
30 W ?131,$C(13) W:EALNE("ULC")="-" ! W EALNE("UL")
31 ;
32 W !,"5. Social Security Number",?30,"|6. Claim Number",?60,"|7. Date of Birth",?95,"|8. Religion"
33 W !?4,@EASD@(5),?30,"| ",@EASD@(6),?60,"| ",@EASD@(7),?95,"| ",@EASD@(8)
34 W ?131,$C(13) W:EALNE("ULC")="-" ! W EALNE("UL")
35 ;
36 W !,"9A. Current Mailing Address",?60,"|9B. City",?95,"|9C. State",?110,"|9D. Zip"
37 W !?4,@EASD@("9A"),?60,"| ",@EASD@("9B"),?95,"| ",@EASD@("9C"),?110,"| ",@EASD@("9D")
38 W ?131,$C(13) W:EALNE("ULC")="-" ! W EALNE("UL")
39 ;
40 W !,"9E. County ",?40,"|10. Home Telephone Number ",?85,"|11. Work Telephone Number "
41 W !?4,@EASD@("9E"),?40,"| ",@EASD@(10),?85,"| ",@EASD@(11)
42 W ?131,$C(13) W:EALNE("ULC")="-" ! W EALNE("UL")
43 ;
44 W !,"12. Current Marital Status: ",@EASD@(12)
45 W ?131,$C(13) W:EALNE("ULC")="-" ! W EALNE("UL")
46 ;
47 W !,"13A. Last Branch of Service",?28,"|13B. Last Entry Date",?52,"|13C.Last Discharge Date",?78,"|13D. Discharge Type",?100,"|13E. Military Service Number"
48 W !?4,@EASD@("13A"),?28,"| ",@EASD@("13B"),?52,"| ",@EASD@("13C"),?78,"| ",@EASD@("13D"),?100,"| ",@EASD@("13E")
49 Q
50 ;
51EXP ; Print VA 10-10EZ Section I, Questions
52 ;
53 W !,EALNE("D"),!?2,"14. Answer Yes or No for the Following Questions"
54 W ?131,$C(13) W:EALNE("ULC")="-" ! W EALNE("UL")
55 ;
56 W !?2,"A1.",?6,"Are You a Purple Heart Award Recipient ",?58,@EASD@("14A1"),?65,"|"
57 W ?131,$C(13) W:EALNE("ULC")="-" ! W EALNE("UL")
58 ;
59 W !?2,"A2.",?6,"Are You a Former Prisoner of War ",?58,@EASD@("14A2"),?65,"|H.",?70,"Do You Have a Military Dental Injury",?126,@EASD@("14H")
60 W ?131,$C(13) W:EALNE("ULC")="-" ! W EALNE("UL")
61 ;
62 W !?2,"B.",?6,"Do You Have a VA Service Connected Rating ",?58,@EASD@("14B"),?65,"|I.",?70,"Do You Have a Spinal Cord Injury ",?126,@EASD@("14I")
63 W ?131,$C(13) W:EALNE("ULC")="-" ! W EALNE("UL")
64 ;
65 W !?2,"B1.",?6,"If Yes, What is Your Rated Percentage ",?58,@EASD@("14B1"),?63,"% |J.",?70,"Are You Eligible for MEDICAID",?126,@EASD@("14J")
66 W ?131,$C(13) W:EALNE("ULC")="-" ! W EALNE("UL")
67 ;
68 W !?2,"C.",?6,"Are You Receiving a VA Pension: ",?58,@EASD@("14C"),?65,"|K.",?70,"Are You Enrolled in MEDICARE Hospital Insurance Part A",?126,@EASD@("14K")
69 W ?131,$C(13) W:EALNE("ULC")="-" ! W EALNE("UL")
70 ;
71 W !?2,"D.",?6,"Are You Retired From The Military: ",?58,@EASD@("14D"),?65,"|K1.",?70,"Effective Date",?110,@EASD@("14K1")
72 W ?131,$C(13) W:EALNE("ULC")="-" ! W EALNE("UL")
73 ;
74 W !?2,"D1.",?6,"Was Your Retirement The Result Of a Disability: ",?58,@EASD@("14D1"),?65,"|L.",?70,"Are You Enrolled in MEDICARE Hospital Insurance Part B",?126,@EASD@("14L")
75 W ?131,$C(13) W:EALNE("ULC")="-" ! W EALNE("UL")
76 ;
77 W !?2,"D2.",?6,"Were You Regularly Retired (20+yrs.)",?58,@EASD@("14D2"),?65,"|L1.",?70,"Effective Date",?110,@EASD@("14L1")
78 W ?131,$C(13) W:EALNE("ULC")="-" ! W EALNE("UL")
79 ;
80 W !?2,"E.",?6,"Were You Exposed To Toxins In The Gulf War",?58,@EASD@("14E"),?65,"|M.",?70,"MEDICARE Claim Number",?110,@EASD@("14M")
81 W ?131,$C(13) W:EALNE("ULC")="-" ! W EALNE("UL")
82 ;
83 W !?2,"F.",?6,"Were You Exposed To Agent Orange",?58,@EASD@("14F"),?65,"|N.",?70,"Name Exactly As It Appears On Your MEDICARE Card"
84 W ?131,$C(13) W:EALNE("ULC")="-" ! W $E(EALNE("UL"),1,65)
85 ;
86 W !?2,"G.",?6,"Were You Exposed to Radiation",?58,@EASD@("14G"),?65,"| ",@EASD@("14N")
87 Q
88 ;
89EMP ;
90 W !,EALNE("D")
91 W !,"15A. Veteran's Employment Status ",$P(@EASD@("15A"),U),?58,"| 15B. Company Name, Address, Telephone"
92 W !?5,"Date of Retirement: ",$P(@EASD@("15A"),U,2),?58,"| ",$P(@EASD@("15B"),U)," ",$P(@EASD@("15B"),U,3)
93 W !?7,"(If employed or retired, complete 15B)",?58,"| ",$P(@EASD@("15B"),U,2)
94 W ?131,$C(13) W:EALNE("ULC")="-" ! W EALNE("UL")
95 ;
96 W !,"16A. Spouse's Employment Status ",$P(@EASD@("16A"),U),?58,"| 16B. Company Name, Address, Telephone"
97 W !?5,"Date of Retirement: ",$P(@EASD@("16A"),U,2),?58,"| ",$P(@EASD@("16B"),U)," ",$P(@EASD@("16B"),U,3)
98 W !?7,"(If employed or retired, complete 16B)",?58,"| ",$P(@EASD@("16B"),U,2)
99 W ?131,$C(13) W:EALNE("ULC")="-" ! W EALNE("UL")
100 Q
101 ;
102INS ;
103 W !,"17. Does The Veteran Have Health Insurance",?65,"|18. Does The Spouse Have Health Insurance"
104 W !," (Other Than Medicare) ",@EASD@(17),?65,"| (Other Than Medicare) ",@EASD@(18)
105 W ?131,$C(13) W:EALNE("ULC")="-" ! W EALNE("UL")
106 ;
107 W !,"17A. Veteran's Health Insurance Co.",?65,"|18A. Spouse's Health Insurance Co."
108 W !?1,@EASD@("17A"),?65,"| ",@EASD@("18A")
109 W !
110 W ?131,$C(13) W:EALNE("ULC")="-" ! W EALNE("UL")
111 ;
112 W !,"17B. Name of Policy Holder ",@EASD@("17B"),?65,"|18B. Name of Policy Holder ",@EASD@("18B")
113 W ?131,$C(13) W:EALNE("ULC")="-" ! W EALNE("UL")
114 ;
115 W !,"17C. Policy Number",?32,"|17D. Group Code",?65,"|18C. Policy Number",?98,"|18D. Group Code"
116 W !,@EASD@("17C"),?32,"| ",@EASD@("17D"),?65,"| ",@EASD@("18C"),?98,"| ",@EASD@("18D")
117 W ?131,$C(13) W:EALNE("ULC")="-" ! W EALNE("UL")
118 Q
119 ;
120NOK ;
121 W !,"19A. Name, Address and Relationship Of Next of Kin",?80,"|19B. Home Telephone ",@EASD@("19B")
122 W !?1,$P(@EASD@("19A"),U)," - ",$P(@EASD@("19A"),U,3),?80,"|19C. Work Telephone ",@EASD@("19C")
123 W !?1,$P(@EASD@("19A"),U,2),?80,"|"
124 W ?131,$C(13) W:EALNE("ULC")="-" ! W EALNE("UL")
125 ;
126 W !,"20A. Name, Adress and Relationship Of Emergency Contact",?80,"|20B. Home Telephone ",@EASD@("20B")
127 W !?1,$P(@EASD@("20A"),U)," - ",$P(@EASD@("20A"),U,3),?80,"|20C. Work Telephone ",@EASD@("20C")
128 W !?1,$P(@EASD@("20A"),U,2),?80,"|"
129 W ?131,$C(13) W:EALNE("ULC")="-" ! W EALNE("UL")
130 ;
131 W !,"21. I DESIGNATE THE FOLLOWING INDIVIDUAL TO RECEIVE POSSESSION OF ALL MY PERSONAL PROPERTY LEFT ON PREMISES UNDER VA CONTROL AFTER"
132 W !," MY DEPARTURE OR AT THE TIME OF MY DEATH. (This does not constitute a will or transfer of title.) ",@EASD@(21)
133 W ?131,$C(13) W:EALNE("ULC")="-" ! W EALNE("UL")
134 ;
135 W !,"22A. Is Need For Care Due To On The Job Injury ",@EASD@("22A"),?65,"|22B. Is Need For Care Due To Accident ",@EASD@("22B")
136 Q
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