| 1 | EASEZPF3 ; ALB/SCK - Print 1010EZ Enrollment Form Cont. ; 10/25/2000
|
|---|
| 2 | ;;1.0;ENROLLMENT APPLICATION SYSTEM;;Mar 15, 2001
|
|---|
| 3 | ;
|
|---|
| 4 | EN(EALNE,EAINFO) ;
|
|---|
| 5 | N EASIGN
|
|---|
| 6 | ;
|
|---|
| 7 | I $$GET1^DIQ(712,EAINFO("EASAPP")_",",4)]"" D
|
|---|
| 8 | . S EASIGN=$$GET1^DIQ(712,EAINFO("EASAPP")_",",4.1)
|
|---|
| 9 | S EASIGN=$G(EASIGN)
|
|---|
| 10 | ;
|
|---|
| 11 | D HDR^EASEZPF(.EALNE,.EAINFO)
|
|---|
| 12 | D REL
|
|---|
| 13 | D CON
|
|---|
| 14 | D FT^EASEZPF(.EALNE,.EAINFO)
|
|---|
| 15 | ;
|
|---|
| 16 | Q
|
|---|
| 17 | ;
|
|---|
| 18 | REL ;
|
|---|
| 19 | W !?55,"SECTION III",!,EALNE("DD")
|
|---|
| 20 | W !,?50,"CONSENT TO RELEASE INFORMATION"
|
|---|
| 21 | W !!,"I hereby authorize the Department of Veterans Affairs to disclose any such history, diagnostic and treatment information from"
|
|---|
| 22 | W !,"my medical records (including information relating to the diagnosis, treatment of other therapy for the conditions of"
|
|---|
| 23 | W !,"substance abuse, alcoholism or alcohol abuse, sickle cell anemia, or testing for or infection with the human immunodeficiency"
|
|---|
| 24 | W !,"virus) to the contractor of any health plan contract under which I am apparently eligible for medical care or payment of the"
|
|---|
| 25 | W !,"expense of care or to any other party against whom liability is asserted. I understand that I may revoke this authorization"
|
|---|
| 26 | W !,"at any time, except to the extent that action has already been taken in reliance on it. Without my express revocation, this"
|
|---|
| 27 | W !,"consent will automatically expire when all action arising from VA's claim for reimbursement for my medical care has been"
|
|---|
| 28 | W !,"completed. I authorize payment of medical benefits to VA for any services for which payment is accepted."
|
|---|
| 29 | ;
|
|---|
| 30 | W !,EALNE("D")
|
|---|
| 31 | W !,"SOCIAL SECURITY NUMBER ",EAINFO("SSN"),?80,"| DATE OF BIRTH ",$G(^TMP("EASEZ",$J,1,7))
|
|---|
| 32 | W ?131,$C(13) W:EALNE("ULC")="-" ! W EALNE("UL")
|
|---|
| 33 | W !,"SIGNATURE OF PATIENT",?80,"| DATE (mm/dd/yyyy)",!
|
|---|
| 34 | W ?131,$C(13) W:EALNE("ULC")="-" ! W EALNE("UL")
|
|---|
| 35 | W !!,EALNE("D"),!?50,"III - CONSENT AND SIGNATURE"
|
|---|
| 36 | W !?30,"ALL APPLICANTS MUST SIGN AND DATE THE APPLICATION FOR HEALTH BENEFITS"
|
|---|
| 37 | W !,EALNE("D")
|
|---|
| 38 | W !,"The Paperwork Reduction Act of 1995 requires us to notify you that this information collection is in accordance with the"
|
|---|
| 39 | W !,"clearance requirements of section 3507 of the Paperwork Reduction Act of 1995. We may not conduct or sponsor, and you are"
|
|---|
| 40 | W !,"not required to respond to, a collection of information unless it displays a valid OMB number. We anticipate that the"
|
|---|
| 41 | W !,"time expended by all individuals who must complete this form will average 20 minutes. This includes the time it will take"
|
|---|
| 42 | W !,"to read instructions, gather the necessary facts and fill out the form."
|
|---|
| 43 | W !!,"Privacy Act Information: The VA is asking you to provide the information on this form under Title 38, United States Code, "
|
|---|
| 44 | W !,"sections 1710, 1712, and 1722 in order for VA to determine your eligibility for medical benefits. The information you supply"
|
|---|
| 45 | W !,"may be verified through a computer-matching program. VA may disclose the information that you put on the form as permitted by"
|
|---|
| 46 | W !,"law. VA may make a ""routine use"" disclosure for: civil or criminal law enforcement, congressional communications, "
|
|---|
| 47 | W !,"epidemiological or research studies, the collection of money owed to the United States, litigation in which the United States"
|
|---|
| 48 | W !,"is a party or has interest, the administration of VA programs and delivery of VA benefits, verification of identity and status,"
|
|---|
| 49 | W !,"and personnel administration. You do not have to provide the information to VA, but if you don't, we will be unable to "
|
|---|
| 50 | W !,"process your request and serve your medical needs. Failure to furnish the information will not have any affect on any other "
|
|---|
| 51 | W !,"benefits to which you may be entitled. If you give VA your Social Security Number, VA will use it to administer your VA "
|
|---|
| 52 | W !,"benefits, to identify veterans and persons claiming or receiving VA benefits and their records, and for other purposes "
|
|---|
| 53 | W !,"authorized or required by law."
|
|---|
| 54 | Q
|
|---|
| 55 | ;
|
|---|
| 56 | CON ;
|
|---|
| 57 | W !!,"CO-PAYMENT NOTICE: If you are a 0% service-connected noncompensable or a nonservice-connected veteran (and are not an"
|
|---|
| 58 | W !,"Ex-POW, WWI veteran or VA pensioner) AND your household income (or combined income and net worth) exceeds the established"
|
|---|
| 59 | W !,"threshold, you may be eligible for enrollment only if you agree to pay VA co-payments for treatment of your NSC conditions."
|
|---|
| 60 | W !,"By signing this application you are agreeing to pay the applicable VA co-payment if required by law.",!
|
|---|
| 61 | W ?131,$C(13) W:EALNE("ULC")="-" ! W EALNE("UL")
|
|---|
| 62 | W !,?5,"I CERTIFY THE FOREGOING STATEMENT(S) ARE TRUE AND CORRECT TO THE BEST OF MY KNOWLEDGE AND ABILITY.",?110,"|Date (mm/dd/yyyy)"
|
|---|
| 63 | W !?110,"|",!,"SIGN HERE "
|
|---|
| 64 | I $G(EASIGN)]"" W "SIGNATURE OF APPLICANT OR APPLICANT'S REPRESENTATIVE HAS BEEN VERIFIED",?110,"| ",EASIGN
|
|---|
| 65 | W ?131,$C(13) W:EALNE("ULC")="-" ! W EALNE("UL")
|
|---|
| 66 | ;
|
|---|
| 67 | W !,EALNE("DD"),!?24,"THE LAW PROVIDES SEVERE PENALTIES FOR WILLFUL SUBMISSION OF FALSE INFORMATION."
|
|---|
| 68 | Q
|
|---|
