source: FOIAVistA/trunk/r/ENROLLMENT_APPLICATION_SYSTEM-EAS/EASEZRP1.m@ 1713

Last change on this file since 1713 was 628, checked in by George Lilly, 15 years ago

initial load of FOIAVistA 6/30/08 version
File size: 5.5 KB
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1EASEZRP1 ;ALB/AMA - Print 1010EZR
2 ;;1.0;ENROLLMENT APPLICATION SYSTEM;**57**;Mar 15, 2001
3 ;
4EN(EALNE,EAINFO) ;Entry point for VA 10-10EZR, page 1
5 ; Called from EN^EASEZRPF
6 N EASD,X
7 ;
8 S EASD=$NA(^TMP("EASEZR",$J,1))
9 D HDRMAIN^EASEZRPF(.EALNE)
10 D DEM
11 D II
12 D EI
13 ;
14 D FT^EASEZRPF(.EALNE,.EAINFO)
15 S EAINFO("VET")=@EASD@(2),EAINFO("SSN")=@EASD@(5)
16 Q
17 ;
18DEM ; Print VA 10-10EZR Section I, Demographic information
19 ;
20 W !?50,"SECTION I - GENERAL INFORMATION"
21 W ?131,$C(13) W:EALNE("ULC")="-" ! W EALNE("UL")
22 W !?18,"Federal law provides criminal penalties, including a fine and/or imprisonment for up to 5 years,"
23 W !?20,"for concealing a material fact or making a materially false statement. (See 18 U.S.C. 1001)"
24 W ?131,$C(13) W:EALNE("ULC")="-" ! W EALNE("UL")
25 ;
26 W !,"1. VETERAN'S NAME (Last, First, Middle Name)",?66,"|2. OTHER NAMES USED"
27 W !?3,@EASD@(2),?66,"| ",@EASD@(3)
28 W ?131,$C(13) W:EALNE("ULC")="-" ! W EALNE("UL")
29 ;
30 W !,"3. GENDER",?20,"|4. SOCIAL SECURITY NUMBER",?55,"|5. DATE OF BIRTH (mm/dd/yyyy)",?95,"|6. CURRENT MARITAL STATUS"
31 W !?3,@EASD@(4),?20,"| ",@EASD@(5),?55,"| ",@EASD@(7),?95,"| ",@EASD@(12)
32 W ?131,$C(13) W:EALNE("ULC")="-" ! W EALNE("UL")
33 ;
34 W !,"7. PERMANENT ADDRESS (Street)",?42,"|7A. CITY",?66,"|7B. STATE",?105,"|7C. ZIP"
35 W !?3,@EASD@("9A"),?42,"| ",@EASD@("9B"),?66,"| ",@EASD@("9C"),?105,"| ",@EASD@("9D")
36 W ?131,$C(13) W:EALNE("ULC")="-" ! W EALNE("UL")
37 ;
38 W !,"7D. COUNTY",?34,"|7E. HOME TELEPHONE NUMBER (Include area code)",?82,"|7F. E-MAIL ADDRESS"
39 W !?4,@EASD@("9E"),?34,"| ",@EASD@(10),?82,"| ",@EASD@("11A")
40 W ?131,$C(13) W:EALNE("ULC")="-" ! W EALNE("UL")
41 ;
42 W !,"7G. CELLULAR TELEPHONE NUMBER (Include area code)",?66,"|7H. PAGER NUMBER (Include area code)"
43 W !?4,@EASD@("11G"),?66,"| ",@EASD@("11H")
44 W ?131,$C(13) W:EALNE("ULC")="-" ! W EALNE("UL")
45 ;
46 W !,"8. NAME, ADDRESS AND RELATIONSHIP OF NEXT OF KIN",?83,"|8A. NEXT OF KIN'S HOME TELEPHONE NUMBER"
47 W !?3,$P(@EASD@("19A"),U)," - ",$P(@EASD@("19A"),U,4),?83,"| (Include area code) ",@EASD@("19B")
48 W ?131,$C(13) W:EALNE("ULC")="-" ! F X=1:1:84 W " "
49 W $E(EALNE("UL"),1,48)
50 W !?3,$P(@EASD@("19A"),U,2),?83,"|8B. NEXT OF KIN'S WORK TELEPHONE NUMBER"
51 W !?3,$P(@EASD@("19A"),U,3),?83,"| (Include area code) ",@EASD@("19C")
52 W ?131,$C(13) W:EALNE("ULC")="-" ! W EALNE("UL")
53 ;
54 W !,"9. NAME, ADDRESS AND RELATIONSHIP OF EMERGENCY CONTACT",?83,"|9A. EMERGENCY CONTACT'S HOME TELEPHONE NUMBER"
55 W !?3,$P(@EASD@("20A"),U)," - ",$P(@EASD@("20A"),U,4),?83,"| (Include area code) ",@EASD@("20B")
56 W ?131,$C(13) W:EALNE("ULC")="-" ! F X=1:1:84 W " "
57 W $E(EALNE("UL"),1,48)
58 W !?3,$P(@EASD@("20A"),U,2),?83,"|9B. EMERGENCY CONTACT'S WORK TELEPHONE NUMBER"
59 W !?3,$P(@EASD@("20A"),U,3),?83,"| (Include area code) ",@EASD@("20C")
60 W ?131,$C(13) W:EALNE("ULC")="-" ! W EALNE("UL")
61 ;
62 W !,"10. INDIVIDUAL TO RECEIVE POSSESSION OF YOUR PERSONAL PROPERTY LEFT ON PREMISES UNDER VA CONTROL AFTER YOUR DEPARTURE OR AT THE"
63 W !?4,"TIME OF DEATH. Note: This does not constitute a will or transfer of title. ",@EASD@(21)
64 W ?131,$C(13) W:EALNE("ULC")="-" ! W EALNE("UL")
65 Q
66 ;
67II ; Print VA 10-10EZR SECTION II - INSURANCE INFORMATION
68 ;
69 W !?23,"SECTION II - INSURANCE INFORMATION (Use a separate sheet for additional information)"
70 W ?131,$C(13) W:EALNE("ULC")="-" ! W EALNE("UL")
71 ;
72 W !,"1. ARE YOU COVERED BY HEALTH INSURANCE,",?49,"|2. HEALTH INSURANCE COMPANY NAME, ADDRESS AND TELEPHONE NUMBER"
73 W !?3,"INCLUDING COVERAGE THROUGH A SPOUSE",?49,"| ",@EASD@("17A")
74 W !?3,"OR ANOTHER PERSON? ",@EASD@(17),?49,"| "
75 W ?131,$C(13) W:EALNE("ULC")="-" ! W $E(EALNE("UL"),1,49)
76 ;
77 W !,"3. NAME OF POLICY HOLDER",?49,"| ",$P(@EASD@("17E"),U,2)
78 W !?3,@EASD@("17B"),?49,"| ",@EASD@("17I")
79 W ?131,$C(13) W:EALNE("ULC")="-" ! W EALNE("UL")
80 ;
81 W !,"4. POLICY NUMBER",?41,"|5. GROUP CODE",?70,"|6. ARE YOU ELIGIBLE FOR MEDICAID?"
82 W !?3,@EASD@("17C"),?41,"| ",@EASD@("17D"),?70,"| ",@EASD@("14J")
83 W ?131,$C(13) W:EALNE("ULC")="-" ! W EALNE("UL")
84 ;
85 W !,"7. ARE YOU ENROLLED IN MEDICARE HOSPITAL INSURANCE PART A?",?70,"|7A. EFFECTIVE DATE (mm/dd/yyyy)"
86 W !?3,@EASD@("14K"),?70,"| ",@EASD@("14K1")
87 W ?131,$C(13) W:EALNE("ULC")="-" ! W EALNE("UL")
88 ;
89 W !,"8. ARE YOU ENROLLED IN MEDICARE HOSPITAL INSURANCE PART B?",?70,"|8A. EFFECTIVE DATE (mm/dd/yyyy)"
90 W !?3,@EASD@("14L"),?70,"| ",@EASD@("14L1")
91 W ?131,$C(13) W:EALNE("ULC")="-" ! W EALNE("UL")
92 ;
93 W !,"9. NAME EXACTLY AS IT APPEARS ON YOUR MEDICARE CARD",?70,"|10. MEDICARE CLAIM NUMBER"
94 W !?3,@EASD@("14N"),?70,"| ",@EASD@("14M")
95 W ?131,$C(13) W:EALNE("ULC")="-" ! W EALNE("UL")
96 Q
97 ;
98EI ; Print VA 10-10EZR SECTION III - EMPLOYMENT INFORMATION
99 ;
100 W !?48,"SECTION III - EMPLOYMENT INFORMATION"
101 W ?131,$C(13) W:EALNE("ULC")="-" ! W EALNE("UL")
102 ;
103 W !,"1. VETERAN'S EMPLOYMENT STATUS",?47,"|1A. COMPANY NAME, ADDRESS AND TELEPHONE NUMBER"
104 W !?3,$P(@EASD@("15A"),U),?47,"| ",$P(@EASD@("15B"),U)
105 W !,"Date of retirement (mm/dd/yyyy) ",$P(@EASD@("15A"),U,2),?47,"| ",$P(@EASD@("15B"),U,2)
106 W !,"If employed or retired, complete item 1A",?47,"| ",$P(@EASD@("15B"),U,3)
107 W !?47," ",$P(@EASD@("15B"),U,4)
108 W ?131,$C(13) W:EALNE("ULC")="-" ! W EALNE("UL")
109 ;
110 W !,"2. SPOUSE'S EMPLOYMENT STATUS",?47,"|2A. COMPANY NAME, ADDRESS AND TELEPHONE NUMBER"
111 W !?3,$P(@EASD@("16A"),U),?47,"| ",$P(@EASD@("16B"),U)
112 W !,"Date of retirement (mm/dd/yyyy) ",$P(@EASD@("16A"),U,2),?47,"| ",$P(@EASD@("16B"),U,2)
113 W !,"If employed or retired, complete item 2A",?47,"| ",$P(@EASD@("16B"),U,3)
114 W !?47,"| ",$P(@EASD@("16B"),U,4)
115 W ?131,$C(13) W:EALNE("ULC")="-" ! W EALNE("UL")
116 Q
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