source: WorldVistAEHR/trunk/r/ENROLLMENT_APPLICATION_SYSTEM-EAS/EASEZRP2.m@ 691

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1EASEZRP2 ;ALB/AMA - Print 1010EZR, Cont., Page 2
2 ;;1.0;ENROLLMENT APPLICATION SYSTEM;**57**;Mar 15, 2001
3 ;
4 Q
5 ;
6EN(EALNE,EAINFO,EASDG) ; Entry point, called from EN^EASEZRPF
7 ; Input
8 ; EALNE - Array of line formats for output
9 ; EAINFO - Application Data array, see SETUP^EASEZRPF
10 ; EASDG - Flag variable to signify request to print from DG options
11 ;
12 N EASD
13 ;
14 D HDR^EASEZRPF(.EALNE,.EAINFO)
15 S EASD=$NA(^TMP("EASEZR",$J,2))
16 D PAP
17 D FD
18 D DEP
19 D INC
20 D EXP
21 ;
22 D FT^EASEZRPF(.EALNE,.EAINFO)
23 Q
24 ;
25PAP ; Print SECTION IV - PAPERWORK REDUCTION ACT AND PRIVACY ACT INFORMATION
26 ;
27 W !?34,"SECTION IV - PAPERWORK REDUCTION ACT AND PRIVACY ACT INFORMATION"
28 W ?131,$C(13) W:EALNE("ULC")="-" ! W EALNE("UL")
29 ;
30 W !?5,"The Paperwork Reduction Act of 1995 requires us to notify you that this information collection is in accordance with the"
31 W !,"clearance requirements of Section 3507 of the Paperwork Reduction Act of 1995. We may not conduct or sponsor, and you are not"
32 W !,"required to respond to, a collection of information unless it displays a valid OMB number. We anticipate that the time expended by"
33 W !,"all individuals who must complete this form will average 24 minutes. This includes the time it will take to read instructions,"
34 W !,"gather the necessary facts and fill out the form."
35 W !?5,"Privacy Act Information: VA is asking you to provide the information on this form under 38 U.S.C. Sections 1710, 1712, and"
36 W !,"1722 in order for VA to determine your eligibility for medical benefits. Information you supply may be verified through a"
37 W !,"computer-matching program. VA may disclose the information that you put on the form as permitted by law. VA may make a ""routine"
38 W !,"use"" disclosure of the information as outlined in the Privacy Act systems of records notices and in accordance with the VHA Notice"
39 W !,"of Privacy Practices. You do not have to provide the information to VA, but if you don't, VA may be unable to process your request"
40 W !,"and serve your medical needs. Failure to furnish the information will not have any affect on any other benefits to which you may"
41 W !,"be entitled. If you provide VA your Social Security Number, VA will use it to administer your VA benefits. VA may also use this"
42 W !,"information to identify veterans and persons claiming or receiving VA benefits and their records, and for other purposes"
43 W !,"authorized or required by law."
44 W ?131,$C(13) W:EALNE("ULC")="-" ! W EALNE("UL")
45 Q
46 ;
47FD ; Print VA 10-10EZR SECTION V - FINANCIAL DISCLOSURE
48 ;
49 W !?49,"SECTION V - FINANCIAL DISCLOSURE"
50 W ?131,$C(13) W:EALNE("ULC")="-" ! W EALNE("UL")
51 ;
52 W !?5,"Failure to disclose your previous year's financial information may affect your eligibility for health care benefits. Your"
53 W !,"financial information is used by VA to accurately determine if you should be responsible for copayments for office visits, pharmacy,"
54 W !,"inpatient, nursing home and long term care, and for some veterans, priority for enrollment. You are not required to provide this"
55 W !,"information. However, completing the financial dislosure section results in a more accurate determination of your eligibility for"
56 W !,"health care services/benefits."
57 ;
58 N EZRY,EZRN S (EZRY,EZRN)="___"
59 ; IF NO ENTRY, THEN NO MEANS TEST, SO NO ANSWER
60 ; IF @EASD@(998)="Y", THEN VET DECLINES TO GIVE INFO, SO ANSWER "NO"
61 I $D(@EASD@(998)) D
62 . S:@EASD@(998)="YES" EZRN=" X "
63 . S:@EASD@(998)="NO" EZRY=" X "
64 ;
65 W !?3,EZRN," NO, I DO NOT WISH TO PROVIDE INFORMATION IN SECTIONS VI THROUGH IX. I understand that VA is currently not enrolling"
66 W !,"veterans who decline to provide financial information unless other special eligibility factors exist. However, if I am already"
67 W !,"enrolled, I agree to pay the applicable VA copayments. (Sign and date the application in Section XI.)"
68 ;
69 W !?3,EZRY," YES, I WILL PROVIDE SPECIFIC INCOME AND/OR ASSET INFORMATION TO ESTABLISH MY ELIGIBILITY FOR CARE. (Complete all sections"
70 W !,"below that apply to you with last calendar year's information. Sign and date the application in Section XI.)"
71 W ?131,$C(13) W:EALNE("ULC")="-" ! W EALNE("UL")
72 Q
73 ;
74DEP ; Print out VA 10-10EZR Section VI, Dependent Information
75 ;
76 W !?24,"SECTION VI - DEPENDENT INFORMATION (Use a separate sheet for additional dependents)"
77 W ?131,$C(13) W:EALNE("ULC")="-" ! W EALNE("UL")
78 ;
79 W !,"1. SPOUSE'S NAME (Last, First, Middle Name)",?49,"|2. CHILD'S NAME (Last, First, Middle Name)",?94,"|2A. CHILD'S RELATIONSHIP TO YOU"
80 W !?3,$P(@EASD@(1),U),?49,"| ",@EASD@(2),?94,"| ",@EASD@(9)
81 W ?131,$C(13) W:EALNE("ULC")="-" ! W EALNE("UL")
82 ;
83 W !,"1A. SPOUSE'S MAIDEN NAME",?49,"|2B. CHILD'S SOCIAL SECURITY NUMBER",?94,"|2C. DATE CHILD BECAME YOUR DEPENDENT"
84 W !?4,$P(@EASD@(1),U,2),?49,"| ",@EASD@(7),?94,"| ",@EASD@(11)
85 W ?131,$C(13) W:EALNE("ULC")="-" ! W EALNE("UL")
86 ;
87 W !,"1B. SPOUSE'S SOCIAL SECURITY NUMBER ",@EASD@(3),?66,"|2D. CHILD'S DATE OF BIRTH (mm/dd/yyyy) ",@EASD@(5)
88 W ?131,$C(13) W:EALNE("ULC")="-" ! W EALNE("UL")
89 ;
90 W !,"1C. SPOUSE'S DATE OF BIRTH (mm/dd/yyyy)",?44,"|1D. DATE OF MARRIAGE (mm/dd/yyyy)",?84,"|2E. WAS CHILD PREMANENTLY AND TOTALLY"
91 W !?4,@EASD@(4),?44,"| ",@EASD@(10),?84,"| DISABLED BEFORE THE AGE OF 18? ",@EASD@(14)
92 W ?131,$C(13) W:EALNE("ULC")="-" ! W EALNE("UL")
93 ;
94 W !,"1E. SPOUSE'S ADDRESS AND TELEPHONE NUMBER (Street, City, State, ZIP)",?84,"|2F. IF CHILD IS BETWEEN 18 AND 23 YEARS"
95 W !?4,$P(@EASD@(6),U),?84,"| OF AGE, DID CHILD ATTEND SCHOOL LAST"
96 W !?4,$P(@EASD@(6),U,2),?84,"| CALENDAR YEAR? ",@EASD@(15)
97 W !?4,@EASD@(8),?84,"|"
98 W ?131,$C(13) W:EALNE("ULC")="-" ! W EALNE("UL")
99 ;
100 W !,"3. IF YOUR SPOUSE OR DEPENDENT CHILD DID NOT LIVE WITH YOU LAST",?65,"|2G. EXPENSES PAID BY YOUR DEPENDENT CHILD FOR COLLEGE, VOCATIONAL"
101 W !?3,"YEAR, ENTER THE AMOUNT YOU CONTRIBUTED TO THEIR SUPPORT",?65,"| REHABILITATION OR TRAINING (e.g., tuition, books, materials)"
102 W !?6,"SPOUSE $ ",$P(@EASD@(12),U),?35,"CHILD $ ",$P(@EASD@(12),U,2),?65,"|",?73,"$ ",@EASD@(13)
103 W ?131,$C(13) W:EALNE("ULC")="-" ! W EALNE("UL")
104 Q
105 ;
106INC ; Print out VA 10-10EZ Section VII, Gross Annual Income information
107 ;
108 I $G(EASDG),+@EASD@(999) W !?6,"SECTION VII - PREVIOUS CALENDAR YEAR GROSS ANNUAL INCOME OF VETERAN, SPOUSE AND DEPENDENT CHILDREN (INCOME YEAR: ",@EASD@(999),")"
109 E W !?17,"SECTION VII - PREVIOUS CALENDAR YEAR GROSS ANNUAL INCOME OF VETERAN, SPOUSE AND DEPENDENT CHILDREN"
110 W ?131,$C(13) W:EALNE("ULC")="-" ! W EALNE("UL")
111 ;
112 W !?69,"|",?76,"VETERAN",?90,"|",?97,"SPOUSE",?110,"|",?117,"CHILD 1"
113 W ?131,$C(13) W:EALNE("ULC")="-" ! W EALNE("UL")
114 ;
115 W !,"1. GROSS ANNUAL INCOME FROM EMPLOYMENT (e.g., wages, bonuses, tips)",?69,"| $ ",$P(@EASD@("2C1"),U),?90,"| $ ",$P(@EASD@("2C1"),U,2),?110,"| $ ",$P(@EASD@("2C1"),U,3)
116 W !?3,"EXCLUDING INCOME FROM YOUR FARM, RANCH, PROPERTY OR BUSINESS",?69,"|",?90,"|",?110,"|"
117 W ?131,$C(13) W:EALNE("ULC")="-" ! W EALNE("UL")
118 ;
119 W !,"2. NET INCOME FROM YOUR FARM, RANCH, PROPERTY OR BUSINESS",?69,"| $ ",$P(@EASD@("2C3"),U),?90,"| $ ",$P(@EASD@("2C3"),U,2),?110,"| $ ",$P(@EASD@("2C3"),U,3)
120 W ?131,$C(13) W:EALNE("ULC")="-" ! W EALNE("UL")
121 ;
122 W !,"3. LIST OTHER INCOME AMOUNTS (e.g., Social Security, compensation,",?69,"| $ ",$P(@EASD@("2C2"),U),?90,"| $ ",$P(@EASD@("2C2"),U,2),?110,"| $ ",$P(@EASD@("2C2"),U,3)
123 W !?3,"pension, interest, dividends). EXCLUDING WELFARE",?69,"|",?90,"|",?110,"|"
124 W ?131,$C(13) W:EALNE("ULC")="-" ! W EALNE("UL")
125 Q
126 ;
127EXP ; Print out VA 10-10EZR Section VIII, Deductible Expense Information
128 ;
129 I $G(EASDG),+@EASD@(999) W !?26,"SECTION VIII - PREVIOUS CALENDAR YEAR DEDUCTIBLE EXPENSES (INCOME YEAR: ",@EASD@(999),")"
130 E W !?37,"SECTION VIII - PREVIOUS CALENDAR YEAR DEDUCTIBLE EXPENSES"
131 W ?131,$C(13) W:EALNE("ULC")="-" ! W EALNE("UL")
132 ;
133 W !,"1. NON-REIMBURSED MEDICAL EXPENSES PAID BY YOU OR YOUR SPOUSE (e.g., payments for doctors, dentists,",?110,"| $ ",@EASD@("2D1")
134 W !,"medications, Medicare, health insurance, hospital and nursing home)",?110,"|"
135 W ?131,$C(13) W:EALNE("ULC")="-" ! W EALNE("UL")
136 ;
137 W !,"2. AMOUNT YOU PAID LAST CALENDAR YEAR FOR FUNERAL AND BURIAL EXPENSES FOR YOUR DECEASED SPOUSE OR DEPENDENT",?110,"| $ ",@EASD@("2D2")
138 W !,"CHILD (Also enter spouse or child's information in Section V.)",?110,"|"
139 W ?131,$C(13) W:EALNE("ULC")="-" ! W EALNE("UL")
140 ;
141 W !,"3. AMOUNT YOU PAID LAST CALENDAR YEAR FOR YOUR COLLEGE OR VOCATIONAL EDUCATIONAL EXPENSES (e.g., tuition,",?110,"| $ ",@EASD@("2D3")
142 W !,"books, fees, materials). DO NOT LIST YOUR DEPENDENTS' EDUCATIONAL EXPENSES.",?110,"|"
143 W ?131,$C(13) W:EALNE("ULC")="-" ! W EALNE("UL")
144 Q
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