| 1 | EASEZP64 ; ALB/AMA - Print 1010EZ, Version 6 or greater, Cont. ; 10/25/2000
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| 2 | ;;1.0;ENROLLMENT APPLICATION SYSTEM;**60,57**;Mar 15, 2001
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| 3 | ;
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| 4 | ;This routine carved from EASEZPF3; if the version # of the 1010EZ
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| 5 | ;application is 6.0 or greater, then this routine will be executed.
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| 6 | ;
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| 7 | EN(EALNE,EAINFO) ; Entry point to print Page 3, called from EN^EASEZP6F
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| 8 | N EASIGN,EASD
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| 9 | ;
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| 10 | I $$GET1^DIQ(712,EAINFO("EASAPP")_",",4)]"" D
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| 11 | . S EASIGN=$$GET1^DIQ(712,EAINFO("EASAPP")_",",4.1)
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| 12 | S EASIGN=$G(EASIGN)
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| 13 | ;
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| 14 | D HDR^EASEZP6F(.EALNE,.EAINFO)
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| 15 | S EASD=$NA(^TMP("EASEZ",$J,2))
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| 16 | ;
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| 17 | D NET
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| 18 | D CON
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| 19 | D AOB
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| 20 | D FT^EASEZP6F(.EALNE,.EAINFO)
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| 21 | ;
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| 22 | Q
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| 23 | ;
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| 24 | NET ; Print SECTION X - PREVIOUS CALENDAR YEAR NET WORTH
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| 25 | ;
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| 26 | W !!?18,"SECTION X - PREVIOUS CALENDAR YEAR NET WORTH (Use a separate sheet for additional dependents)"
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| 27 | W ?131,$C(13) W:EALNE("ULC")="-" ! W EALNE("UL")
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| 28 | ;
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| 29 | W !?78,"|",?84,"VETERAN",?96,"|",?102,"SPOUSE",?114,"|",?120,"CHILD 1"
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| 30 | W ?131,$C(13) W:EALNE("ULC")="-" ! W EALNE("UL")
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| 31 | ;
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| 32 | 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,"| $ ",$P(@EASD@("2E1"),U,3)
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| 33 | W !,"certificates of deposit, individual retirement accounts, stocks and bonds)",?78,"|",?96,"|",?114,"|"
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| 34 | W ?131,$C(13) W:EALNE("ULC")="-" ! W EALNE("UL")
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| 35 | ;
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| 36 | 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,"| $ ",$P(@EASD@("2E2"),U,3)
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| 37 | W !,"homes and non-income-producing property. Do not count your primary home.)",?78,"|",?96,"|",?114,"|"
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| 38 | W ?131,$C(13) W:EALNE("ULC")="-" ! W EALNE("UL")
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| 39 | ;
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| 40 | 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,"| $ ",$P(@EASD@("2E3"),U,3)
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| 41 | W !,"MINUS THE AMOUNT YOU OWE ON THESE ITEMS. INCLUDE VALUE OF FARM, RANCH, OR",?78,"|",?96,"|",?114,"|"
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| 42 | W !,"BUSINESS ASSETS. Exclude household effects and family vehicles.",?78,"|",?96,"|",?114,"|"
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| 43 | W ?131,$C(13) W:EALNE("ULC")="-" ! W EALNE("UL")
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| 44 | Q
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| 45 | ;
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| 46 | CON ; Print SECTION XI - CONSENT TO COPAYMENTS
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| 47 | ;
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| 48 | W !!?49,"SECTION XI - CONSENT TO COPAYMENTS"
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| 49 | W ?131,$C(13) W:EALNE("ULC")="-" ! W EALNE("UL")
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| 50 | ;
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| 51 | W !,"If you are a 0% service-connected veteran and do not receive VA monetary benefits or a nonservice-connected veteran (and you are"
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| 52 | W !,"not an Ex-POW, Purple Heart Recipient, WWI veteran or VA pensioner) and your household income (or combined income and net worth)"
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| 53 | W !,"exceeds the established threshold, this application will be considered for enrollment, but only if you agree to pay VA copayments"
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| 54 | W !,"for treatment of your nonservice-connected conditions. If you are such a veteran, by signing this application you are agreeing"
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| 55 | W !,"to pay the applicable VA copayment as required by law.",!
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| 56 | W ?131,$C(13) W:EALNE("ULC")="-" ! W EALNE("UL")
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| 57 | Q
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| 58 | ;
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| 59 | AOB ; Print SECTION XII - ASSIGNMENT OF BENEFITS
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| 60 | ;
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| 61 | W !!?48,"SECTION XII - ASSIGNMENT OF BENEFITS"
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| 62 | W ?131,$C(13) W:EALNE("ULC")="-" ! W EALNE("UL")
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| 63 | ;
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| 64 | W !,"I understand that pursuant to 38 U.S.C. section 1729, VA is authorized to recover or collect from my health plan (HP) for the"
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| 65 | W !,"reasonable charges of nonservice-connected VA medical care or services furnished or provided to me. I hereby authorize payment"
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| 66 | W !,"directly to VA from any HP under which I am covered (including coverage provided under my spouse's HP) that is responsible for"
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| 67 | W !,"payment of the charges for my medical care, including benefits otherwise payable to me or my spouse.",!
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| 68 | W ?131,$C(13) W:EALNE("ULC")="-" ! W EALNE("UL")
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| 69 | ;
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| 70 | W !!?6,"ALL APPLICANTS MUST SIGN AND DATE THIS FORM. REFER TO INSTRUCTIONS WHICH DEFINE WHO CAN SIGN ON BEHALF OF THE VETERAN.",!
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| 71 | W ?131,$C(13) W:EALNE("ULC")="-" ! W EALNE("UL")
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| 72 | ;
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| 73 | W !,"SIGNATURE OF APPLICANT",?90,"| DATE"
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| 74 | I $G(EASIGN)]"" W !,"SIGNATURE OF APPLICANT OR APPLICANT'S REPRESENTATIVE HAS BEEN VERIFIED",?90,"| ",EASIGN,!?90,"|"
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| 75 | E W !?90,"|",!?90,"|"
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| 76 | W ?131,$C(13) W:EALNE("ULC")="-" ! W EALNE("UL")
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| 77 | Q
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