source: FOIAVistA/trunk/r/ENROLLMENT_APPLICATION_SYSTEM-EAS/EASEZRP3.m@ 1154

Last change on this file since 1154 was 628, checked in by George Lilly, 15 years ago

initial load of FOIAVistA 6/30/08 version

File size: 3.9 KB
Line 
1EASEZRP3 ;ALB/AMA - Print 1010EZR, Cont.
2 ;;1.0;ENROLLMENT APPLICATION SYSTEM;**57**;Mar 15, 2001
3 ;
4 Q
5 ;
6EN(EALNE,EAINFO) ; Entry point to print Page 3, called from EN^EASEZRPF
7 ; Input
8 ; EALNE - Array of line formats for output
9 ; EAINFO - Application Data array, see SETUP^EASEZRPF
10 N EASIGN,EASD
11 ;
12 I $$GET1^DIQ(712,EAINFO("EASAPP")_",",4)]"" D
13 . S EASIGN=$$GET1^DIQ(712,EAINFO("EASAPP")_",",4.1)
14 S EASIGN=$G(EASIGN)
15 ;
16 D HDR^EASEZRPF(.EALNE,.EAINFO)
17 S EASD=$NA(^TMP("EASEZR",$J,2))
18 ;
19 D NET
20 D CON
21 D AOB
22 D FT^EASEZRPF(.EALNE,.EAINFO)
23 ;
24 Q
25 ;
26NET ; Print SECTION IX - PREVIOUS CALENDAR YEAR NET WORTH
27 ;
28 W !?18,"SECTION IX - PREVIOUS CALENDAR YEAR NET WORTH (Use a separate sheet for additional dependents)"
29 W ?131,$C(13) W:EALNE("ULC")="-" ! W EALNE("UL")
30 ;
31 W !?78,"|",?84,"VETERAN",?96,"|",?102,"SPOUSE",?114,"|",?120,"CHILD 1"
32 W ?131,$C(13) W:EALNE("ULC")="-" ! W EALNE("UL")
33 ;
34 W !,"1. CASH, AMOUNT IN BANK ACCOUNTS (e.g., checking and savings accounts,",?78,"| $ ",$P(@EASD@("2E1"),U),?96,"| $ ",$P(@EASD@("2E1"),U,2),?114,"| $ ",$P(@EASD@("2E1"),U,3)
35 W !,"certificates of deposit, individual retirement accounts, stocks and bonds)",?78,"|",?96,"|",?114,"|"
36 W ?131,$C(13) W:EALNE("ULC")="-" ! W EALNE("UL")
37 ;
38 W !,"2. MARKET VALUE OF LAND AND BUILDINGS MINUS MORTGAGES AND LIENS (e.g., second",?78,"| $ ",$P(@EASD@("2E2"),U),?96,"| $ ",$P(@EASD@("2E2"),U,2),?114,"| $ ",$P(@EASD@("2E2"),U,3)
39 W !,"homes and non-income-producing property. Do not include your primary home.)",?78,"|",?96,"|",?114,"|"
40 W ?131,$C(13) W:EALNE("ULC")="-" ! W EALNE("UL")
41 ;
42 W !,"3. VALUE OF OTHER PROPERTY OR ASSETS (e.g., art, rare coins, collectibles)",?78,"| $ ",$P(@EASD@("2E3"),U),?96,"| $ ",$P(@EASD@("2E3"),U,2),?114,"| $ ",$P(@EASD@("2E3"),U,3)
43 W !,"MINUS THE AMOUNT YOU OWE ON THESE ITEMS. INCLUDE VALUE OF FARM, RANCH, OR",?78,"|",?96,"|",?114,"|"
44 W !,"BUSINESS ASSETS. Exclude household effects and family vehicles.",?78,"|",?96,"|",?114,"|"
45 W ?131,$C(13) W:EALNE("ULC")="-" ! W EALNE("UL")
46 Q
47 ;
48CON ; Print SECTION X - CONSENT TO COPAYMENTS
49 ;
50 W !?49,"SECTION X - CONSENT TO COPAYMENTS"
51 W ?131,$C(13) W:EALNE("ULC")="-" ! W EALNE("UL")
52 ;
53 W !,"If you are a 0% service-connected veteran and do not receive VA monetary benefits or a nonservice-connected veteran (and you are"
54 W !,"not an Ex-POW, Purple Heart Recipient, WWI veteran or VA pensioner) and your household income (or combined income and net worth)"
55 W !,"exceeds the established threshold, this application will be considered for enrollment, but only if you agree to pay VA copayments"
56 W !,"for treatment of your nonservice-connected conditions. If you are such a veteran, by signing this application you are agreeing"
57 W !,"to pay the applicable VA copayment as required by law.",!
58 W ?131,$C(13) W:EALNE("ULC")="-" ! W EALNE("UL")
59 Q
60 ;
61AOB ; Print SECTION XI - ASSIGNMENT OF BENEFITS
62 ;
63 W !?48,"SECTION XI - ASSIGNMENT OF BENEFITS"
64 W ?131,$C(13) W:EALNE("ULC")="-" ! W EALNE("UL")
65 ;
66 W !,"I understand that pursuant to 38 U.S.C. Section 1729, VA is authorized to recover or collect from my health plan (HP) for the"
67 W !,"reasonable charges of nonservice-connected VA medical care or services furnished or provided to me. I hereby authorize payment"
68 W !,"directly to VA from any HP under which I am covered (including coverage provided under my spouse's HP) that is responsible for"
69 W !,"payment of the charges for my medical care, including benefits otherwise payable to me or my spouse.",!
70 W ?131,$C(13) W:EALNE("ULC")="-" ! W EALNE("UL")
71 ;
72 W !?11,"ALL APPLICANTS MUST SIGN AND DATE THIS FORM. REFER TO INSTRUCTIONS ON WHO CAN SIGN ON BEHALF OF THE VETERAN.",!
73 W ?131,$C(13) W:EALNE("ULC")="-" ! W EALNE("UL")
74 ;
75 W !,"SIGNATURE OF APPLICANT",?90,"| DATE (mm/dd/yyyy)"
76 I $G(EASIGN)]"" W !,"SIGNATURE OF APPLICANT OR APPLICANT'S REPRESENTATIVE HAS BEEN VERIFIED",?90,"| ",EASIGN,!?90,"|"
77 E W !?90,"|",!?90,"|"
78 W ?131,$C(13) W:EALNE("ULC")="-" ! W EALNE("UL")
79 Q
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