| [623] | 1 | FBAA79A ;AISC/GRR-PRINT 7079 CONTINUED ;1/12/98
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| 2 | ;;3.5;FEE BASIS;**12**;JAN 30, 1995
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| 3 | ;;Per VHA Directive 10-93-142, this routine should not be modified.
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| 4 | S DIWL=1,DIWF="WC120" K ^UTILITY($J,"W")
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| 5 | I $D(^FBAAA(DFN,1,FBK,2)) F FBRR=0:0 S FBRR=$O(^FBAAA(DFN,1,FBK,2,FBRR)) Q:FBRR'>0 S FBXX=^(FBRR,0),X=FBXX D ^DIWP
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| 6 | D ^DIWW:$D(FBXX) K FBXX
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| 7 | W !,?40,"FOR VA USE ONLY",!,UL
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| 8 | W !," (5) STATE CODE | (6) COUNTY CODE | (7) TYPE OF | (8) YEAR OF BIRTH | (9) WAR | (10) PURPOSE |",!,?16,"|",?34,"|",?37,"PATIENT",?48,"|",?68,"|",?78,"|",?93,"|"
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| 9 | W !,?7,FBI(5),?16,"|",?23,CC,?34,"|",?41,FBPATT,?48,"|",?58,YOB,?68,"|",?74,POS,?78,"|",?87,POV,?93,"|",!,UL
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| 10 | W !,"STATION OF JURISDICTION",?48,"|",?78,"|",?80," (11) CODE",?100,"| (12) SEX",!,?48,"|",?78,"|",?100,"|"," ",$S(SEX="F":"FEMALE",1:"MALE")
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| 11 | W !,"Veterans Administration",?48,"|",?78,"|",?100,"|",$E(UL,101,120)
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| 12 | W !,FBS(2),?48,"|",?78,"|",?80,$S(CODE=1:"SHORT TERM - 1",CODE=2:"HOME NURSING - 2",CODE=3:"ID CARD STATUS - 3",1:""),?100,"| (13) POW"
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| 13 | W:FBS(3)]"" !,FBS(3),?48,"|",?78,"|",?100,"|"," ",$S(POW="Y":"YES",1:"NO")
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| 14 | W !,FBS(4)," ",SSTCD," ",FBS(6),?48,"|",?78,"|",?100,"|" W:FBS(3)']"" " ",$S(POW="Y":"YES",1:"NO") W !,?48,$E(UL,49,120)
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| 15 | W !,?48,"| APPROVED BY (Name and Title)",?110,"(",$S($D(^VA(200,DUZ,0)):$P(^(0),"^",2),1:""),")",!,?48,"|"
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| 16 | W !,"TELEPHONE: ",FBS(7),?48,"|",?50,FBS(8),!,?48,"|",?50,FBS(9),!,UL
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| 17 | W !,?32,"Information On Veterans Administration Program",!
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| 18 | W !,"Acceptance of this request to render the prescribed services will constitute an agreement which is subject",!,"to the following: ",!
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| 19 | W !,?3,"I. SERVICES. If services are not initiated, please return this document to the Station of Jurisdiction with a brief"
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| 20 | W !,?5,"explanation. Unless approved by the VA, services are limited in type and extent to those shown.",!
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| 21 | W !,?3,"II. PERIOD OF VALIDITY. Service must be performed within the period of validity indicated.",!,?5,"If a longer time is needed, please request an extension.",!
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| 22 | W !,?3,"III. REPORTS. Clinical reports are required when an examination only has been requested. Please ",!,?5,"submit reports promptly to the Station Of Jurisdiction.",!
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| 23 | W !,?3,"IV. STATEMENT OF ACCOUNTS. Submit a Statement of Account in your usual manner. Your statement must",!,?5,"include: (1) Patient's Name; (2) Identification NO.; (3) Treatment (CPT) and Dates Rendered; and (4) Fees.",!
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| 24 | W !,?3,"V. FEES. Fees claimed may not exceed those made to the general public for like services.",!
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| 25 | W !,?3,"VI. PAYMENT. Payment by the VA for services rendered and approved is payment in full.",!
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| 26 | W !,?3,"VII. HOSPITALIZATION. When a need for hospital care is indicated, please call the Station of Jurisdiction",!,?5,"for assistance in admitting the veteran to a VA hospital.",!
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| 27 | W !,?3,"VIII. INQUIRIES. Additional information when required may be obtained by contacting the Station Of Jurisdiction.",!,UL
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| 28 | W !?3,"VA Form 10-7079"
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| 29 | W ?85,"Date Printed: ",$$FMTE^XLFDT(DT),!
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| 30 | Q
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