source: internationalization/trunk/TranslationSpreadsheets/WV-DIALOG-0016.txt@ 1801

English French  Notes   Complete/Exclude
Do you wish to return to Screen #9 to enter missing Income Data?                        
A means test for this encounter date was not found and may be required!                 
Further investigation will be needed.                   
Press ENTER to continue                         
Patient Requires a means Test                   
Primary Means Test Required from '                      
SCENI MEANS TEST EDIT                   
You do not have the appropriate IEMM Security Key.  Contact your supervisor.                    
Do you wish to proceed with the means test at this time                 
No registrations to print from.                 
Registration date/time:                         
Enter the date and time, Entry #, or 'L' for the last registration,                     
 to select the registration you wish to print a 10/10 for.                      
This output requires 132 column output to a PRINTER.                    
Output to SCREEN will be unreadable.                    
FACILITY NOT IDENTIFIED                 
APPLICATION FOR MEDICAL BENEFITS                        
PRINT                   
ENTER 'Y'ES TO PRINT A                  
.  OTHERWISE ENTER 'N'O.                        
NOT APPLICABLE                  
SEE ATTACHMENT FOR PAPERWORK REDUCTION INFORMATION AND PRIVACY ACT INFORMATION                  
PART I - PATIENT DATA                   
1.  Type of benefit applied for:                        
HOSPITAL/OUTPATIENT TREATMENT^DOMICILIARY CARE^HOSPITAL/OUTPATIENT TREATMENT^OUTPATIENT DENTAL^NURSING HOME CARE                        
 3.  Other names used (Alias)                   
 4.  Social Security Number                     
5.   Claim Number                       
| 6.  LOCATION OF CLAIMS FOLDER                 
| 7.  DATE OF BIRTH                     
| 8.  PLACE OF BIRTH                    
9.   PERMANENT ADDRESS                  
 10.  TEMPORARY ADDRESS                         
9A.  STREET ADDRESS:                    
 10A. STREET ADDRESS:                   
9D.  ZIP CODE:                  
10D. ZIP CODE:                  
9F.  HOME TELEPHONE NUMBER:                     
10F. HOME TELEPHONE NUMBER:                     
11. CONFIDENTIAL ADDRESS                        
Not Applicable                  
11A.  STREET ADDRESS:                   
11D.  ZIP CODE:                         
| 11F. START DATE:                      
| STOP DATE:                    
11G. Active Confidential Address Categories                     
13.  MOTHER'S MAIDEN NAME                       
16.  RELIGIOUS PREFERENCE                       
17.  DATE OF PREVIOUS CARE                      
18.  LOCATION OF PREVIOUS CARE                  
19.  SPINAL CORD INJURY                 
PARAPLEGIA-TRAUMATIC                    
QUADRIPLEGIA-TRAUMATIC                  
PARAPLEGIA-NONTRAUMATIC                 
QUADRIPLEGIA-NONTRAUMATIC                       
PART II - EMERGENCY CONTACT DATA                        
1A.  FIRST NEXT OF KIN                  
2A.  SECOND NEXT OF KIN                 
3A.  FIRST CONTACT IN AN EMERGENCY                      
4A.  SECOND CONTACT IN AN EMERGENCY                     
C.  HOME TELEPHONE NUMBER                       
D.  WORK TELEPHONE NUMBER                       
E.  ADDRESS (Number, Street, City, State, ZIP Code)                     
Reg Date/Time:                          
PRINTED:                        
Clerk:                  
AUTOMATED VA FORM 10-10                 
PART III - APPLICANT/SPOUSE DATA                        
1.   APPLICANT'S EMPLOYMENT STATUS:                     
2.   SPOUSE'S EMPLOYMENT STATUS:                        
3. APPLICANT INFORMATION                        
3B.  EMPLOYER (Name, Street Address, City, State, Zip)                  
4B.  EMPLOYER (Name, Street Address, City, State, Zip)                  
3C.  WORK TELEPHONE NUMBER:                     
4C.  WORK TELEPHONE NUMBER:                     
NOT ANSWERED                    
PART IV - MILITARY SERVICE DATA                 
1A. LAST BRANCH OF SERVICE                      
1B. LAST SERVICE NUMBER                 
1C. LAST DATE OF ENTRY                  
1D. LAST DISCHARGE DATE                 
1E. DISCHARGE TYPE                      
2A. PRIOR BRANCH OF SERVICE                     
2B. PRIOR SERVICE NUMBER                        
2C. PRIOR DATE OF ENTRY                 
2D. PRIOR DISCHARGE DATE                        
2E. DISCHARGE TYPE                      
3A. PRIOR BRANCH OF SERVICE                     
3B. PRIOR SERVICE NUMBER                        
3C. PRIOR DATE OF ENTRY                 
3D. PRIOR DISCHARGE DATE                        
3E. DISCHARGE TYPE                      
PART V - ELIGIBILITY STATUS DATA                        
1.  PATIENT TYPE:                       
2.  IS NEED FOR MEDICAL CARE RELATED TO AN                      
3.  IS THE NEED FOR MEDICAL CARE RELATED                        
4.  IS PATIENT ELIGIBLE FOR MEDICAID:                   
    ON THE JOB INJURY:                  
TO AN ACCIDENT:                         
5A. DOES PATIENT HAVE HEALTH INSURANCE                  
5B. IF YES, COVERAGE PROVIDED BY:                       
COVERAGE:                       
PATIENT'S INSURANCE                     
SPOUSE'S INSURANCE                      
NO ACTIVE (UNEXPIRED) INSURANCE ON FILE FOR THIS APPLICANT                      
6.  DOES VETERAN HAVE GI                        
7. PRIMARY ELIGIBILITY CODE                     
8. OTHER ELIGIBILITY CODE                       
9. PERIOD OF SERVICE                    
INSURANCE:                      
10. SERVICE CONNECTED CONDITIONS AS STATED BY APPLICANT:                        
10. RATED SERVICE CONNECTED CONDITIONS:                         
NO RATED SERVICE-CONNECTED CONDITIONS                   
10. SERVICE CONNECTED CONDITIONS:                       
NOT APPLICABLE: NOT A SERVICE-CONNECTED APPLICANT                       
PART VI - INCOME SCREENING DATA OR ANNUAL INCOME                        
1A.  CURRENT MARITAL STATUS:                    
1B.  DATE OF MARRIAGE:                  
2A. WAS PATIENT MARRIED OR SEPARATED AT THE END OF LAST CALENDAR YEAR?:                         
2B. NAME OF SPOUSE                      
2C. SEX OF SPOUSE                       
2D. SPOUSE'S SOCIAL SECURITY NO                 
2E. SPOUSE'S DATE OF BIRTH                      
B. SOCIAL SECURITY NO                   
D. DATE OF BIRTH                        
F. DEPENDENT AS                 
NONE INDICATED                  
4.  PREVIOUS CALENDAR YEAR (                    
) INCOME INFORMATION                    
CHECK ALL APPLICABLE BOXES                      
11.  TOTAL INCOME                       
PART VII - INELIGIBLE/MISSING DATA                      
1.   INELIGIBLE DATE                    
2.   TWX SOURCE                 
3.   TWX CITY                   
4.   TWX STATE                  
6.   VACO DECISION:                     
7.   MISSING DATE                       
8.   TWX SOURCE                 
9.   TWX CITY                   
10.  TWX STATE                  
1.  ELIGIBILITY STATUS                  
2.  STATUS DATE                 
3.  STATUS ENTERED BY                   
PENDING VERIFICATION                    
RE-VERIFY                       
4.  VERIFICATION METHOD                 
5.  SERVICE VERIFICATION DATE                   
6.  RATED DISABILITIES                  
SIGNATURE OF APPLICANT OR APPLICANT'S REPRESENTATIVE                    
FOR VA USE ONLY                 
VA FACILITY NUMBER                      
ADMISSION DATE                  
AUTHORITY FOR ADMISSION OR TREATMENT                    
SUPPLEMENTAL DATA SHEET                 
HEALTH SUMMARY                  
DRUG PROFILE                    
ENCOUNTER FORMS                 
No Type Selected.  HS will not print                    
Select type of Drug Profile                     
11. OTHER ELIGIBILITY DATA                      
L. SERVICE IN PERSIAN GULF THEATER                      
B. PRISONER OF WAR STATUS                       
M. DENTAL INJ. |                        
   TEETH EXTRACTED                      
C. EXPOSURE TO AGENT ORANGE                     
N. SERVICE CONNECTED                    
D. EXPOSURE TO RADIATION                        
O. RECEIVING AID & ATTENDANCE                   
E. COMBAT SERVICE                       
P. RECEIVING HOUSEBOUND                 
F. MILITARY DISABILITY                  
Q. RECEIVING VA PENSION                 
G. VIETNAM SERVICE                      
R. RECEIVING VA DISABILITY                      
H. LEBANON SERVICE                      
S. SERVICE IN SOMALIA                   
I. GRENADA SERVICE                      
T. SERVICE IN YUGOSLAVIA                        
J. PANAMA SERVICE                       
U. PURPLE HEART RECIPIENT                       
K. PERSIAN GULF SERVICE                 
V. VA MONETARY AMOUNT:                  
3.  Other Name(s):                      
NO ALIAS' ON FILE                       
NO REMARKS CURRENTLY ENTERED FOR THIS APPLICANT                 
5.  Fathers Name:                       
NOT SPECIFIED                   
Mothers Name:                   
Mothers Maiden Name:                    
6a. Enrollment Clinic(s):                       
NOT ACTIVELY ENROLLED IN ANY CLINICS AT THIS TIME                       
6b. Future Appointments:                        
NO PENDING APPOINTMENTS ON FILE                 
7a. Last Admission:                     
NO PREVIOUS ADMISSIONS TO THIS FACILITY ON FILE                 
LAST ADMISSION PTF DATA NO LONGER STORED                        
7b. Discharge Diagnosis(es):                    
NO DIAGNOSES ON FILE FOR THIS ADMISSION PERIOD YET                      
7c. Admit Diagnosis:                    
7d. Diagnosis Responsible for Greatest Length of Stay:                          
8.  Eligibility Status:                         
PENDING RE-VERIFICATION                 
UNKNOWN OR NONE                 
| Status Date:                          
Verification Method:                    
ELIGIBLE APPLICANT -- NOT APPLICABLE                    
Ineligible Date:                        
CITY UNKNOWN                    
STATE UNKNOWN                   
VARO DECISION UNKNOWN                   
| TWX Source:                   
TWX City:                       
| TWX State:                    
VARO Decision:                          
9.  Vietnam Service:                    
From:                   
To    :                         
Agent Orange:                   
Reg :                   
Exam  :                         
Reg #:                          
Loc:                    
ION Radiation:                          
Method:                         
Prisoner of War:                        
Where:                          
Combat:                         
Purple Heart:                   
Status:                         
Remarks:                        
10. Next of Kin, Address and Zip Code:                  
Name:                   
KOREAN DMZ                      
NAGASAKI/HIROSHIMA                      
NUCLEAR TESTING                 
NUCLEAR TESTING & NAGASAKI/HIROSHIMA                    
STREET ADDRESS UNKNOWN                  
CITY STATE UNKNOWN                      
GLOBAL SUBSCRIPT LOCATION                       
Unknown/Invalid pointer, DD(                    
GLOBAL NAME                     
Cannot convert the                      
 in the                         
        File 11 and 13 Conversion Problem list                  
MARITAL STATUS (#11) File Conversion Problems:                  
RELIGION (#13) File Converion Problems:                 
No problems                     
Pointer File/Subfile^Field^Problem Description                  
DG*5.3*172                      
DGY(                    
File 11 and 13 Conversion Problems                      
*** Conversion is not necessary! ***                    
Uninstalling patch...                   
*** Not all non-standard entries have been mapped...see DG172 options ***                       
*** Job appears to already be running! ***                      
Are you sure you want to start the conversion process                   
Marital/Religion File Conversion                        
Are you sure you want to stop the background conversion process                 
*** Job will stop soon ***                      
*** Conversion process is NOT running! ***                      
RGPR PRE-IMP MENU                       
DG172                   
RELIGION/MARITAL STATUS REINDEX                 
Reindex Religion and Marital Status file xrefs ...                      
Setting up files that need to be converted...                   
Setting up standard/non-standard mapping file...                        
You can not re-start this process!                      
*** No mapping necessary! ***                   
Select Non-Standard                     
Marital Status:                         
Religion:                       
Religion/Marital Status Conversion                      
Conversion Finished                     
DG172(1,                        
Conversion *NOT* Finished                       
The conversion process appears to have been stopped.                    
To finish the conversion process, restart by using                      
the 'Begin Religion/Marital Status Conversion' option                   
on the CIRN Pre-Implementation Menu.                    
Marital Status                  
Religion                        
 File Non-Standard Entries:                     
All non-standard entries listed above have been removed                 
from their respective files.                    
Entry:                  
 repointed to:                  
 Starting post-install process...                       
 Post-install process has completed.                    
 total records have been identified and corrected.                      
Report cancelled!                       
Means Test Update Report                        
Updated Means Test Listing                      
Run Date:                       
Veteran Name                    
Veteran SSN                     
Year                    
Old Status                      
New Status                      
Income Year                     
Old Means Test Status                   
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