| 1 | English French Notes Complete/Exclude
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| 2 | WARNING: You are about to access a means test for which a hardship has
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| 3 | been authorized. If you proceed, the hardship will be removed
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| 4 | and the means test category will be recalculated! To avoid
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| 5 | this problem, enter NO at the next prompt and use the 'View
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| 6 | a Past Means Test' option should you need to see details of
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| 7 | this means test.
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| 8 | Enter NO to stop editing this means test. Enter YES to continue
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| 9 | Do you want to continue editing this means test?
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| 10 | Last means test is not PENDING ADJUDICATION.
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| 11 | Patient pending adjudication for
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| 12 | Last means test is not REQUIRED.
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| 13 | No means test to change.
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| 14 | MEANS TEST DATE:
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| 15 | SOURCE OF TEST:
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| 16 | CATEGORY A
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| 17 | DG MEANS TEST EVENTS
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| 18 | HARDSHIP?
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| 19 | CURRENT STATUS
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| 20 | TEST DATE
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| 21 | CTGRY CHNGD BY
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| 22 | DT/TM CTGRY CHNGD
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| 23 | TEST STATUS
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| 24 | A Hardship has been granted for
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| 25 | Only the site granting the Hardship may edit it.
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| 26 | Please, contact
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| 27 | to edit the record.
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| 28 | Enter <RETURN> to continue.
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| 29 | DGMTH HARDSHIP
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| 30 | Hardship
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| 31 | Current Means Test Status:
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| 32 | Income Year:
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| 33 | Means Test Date:
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| 34 | Agreed To Pay Deductible:
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| 35 | Hardship?:
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| 36 | Hardship Effective Date:
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| 37 | Site Granting Hardship:
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| 38 | Approved By:
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| 39 | Hardship Reason:
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| 40 | Date Category Last Changed:
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| 41 | Category Last Changed By:
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| 42 | COMMENTS:
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| 43 | YOUR DUZ IS NOT DEFINED!
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| 44 | PATIENT NOT CURRENTLY RESPONSIBLE FOR COPAYMENT CHARGES!
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| 45 | AN ERROR OCCURRED -
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| 46 | Pr^408.32:EMZ
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| 47 | Means Test Status
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| 48 | Hardship Effective Date
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| 49 | Hardship Review Date
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| 50 | Enter a future date if you wish to conduct a review.
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| 51 | Hardship Reason
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| 52 | Are you sure that the hardship should be deleted
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| 53 | Means Test Menu Options^1N^
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| 54 | Future dates are not allowed.
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| 55 | Select Ending Date:
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| 56 | Beginning Date must be prior to Ending Date
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| 57 | Agreed to Pay Deductible Listing
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| 58 | NO ACTIVE PATIENTS WHO HAVE NOT AGREED TO PAY DEDUCTIBLE
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| 59 | Pend Adj
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| 60 | Cat. C
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| 61 | Active Patients Who Have Not Agreed To Pay Deductible
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| 62 | ACTIVE= Sched. Admissions, Dispositions, Pt. Movements, or Clinic Appts.
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| 63 | INHOUSE = Current Inpatient
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| 64 | PAST =
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| 65 | FUTURE = After
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| 66 | Future Appt. w/ Means Test
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| 67 | VAUTC(
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| 68 | VAUTD(
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| 69 | Do you want to generate letters
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| 70 | Enter 'Y'es to generate letters from the listing or
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| 71 | Enter 'N'o to produce the listing, but not the letters.
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| 72 | THERE ARE NO PATIENTS THAT WILL NEED A
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| 73 | TEST AT THEIR NEXT APPOINTMENT FOR THIS DATE RANGE
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| 74 | PEND. ADJ.
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| 75 | Patients Requiring Means Test At Next Appointment
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| 76 | Copay Exemptions That Will Need Updating At Next Appointment
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| 77 | PATIENT ID
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| 78 | APPT DATE/TIME
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| 79 | No review dates found between selected date range.
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| 80 | Hardship Review Date(s)
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| 81 | Patient ID
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| 82 | Review Date
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| 83 | Hardship Review Output
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| 84 | Previous Year Threshold Output
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| 85 | Means Test Using Previous Years Threshold
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| 86 | Date of Test
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| 87 | NO MEANS TEST WITH PREVIOUS YEARS THRESHOLD
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| 88 | TEST STATUS NAME:
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| 89 | DGCAT#^DGBEG^DGEND^DGMTYPT
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| 90 | TEST STATUS Report
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| 91 | STATUS:
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| 92 | No patients found with
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| 93 | test status of
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| 94 | No patients found for requested date range.
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| 95 | Date of
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| 96 | Pend. Adj.
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| 97 | Source
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| 98 | Test
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| 99 | Date of Test:
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| 100 | Completion Date/time:
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| 101 | By:
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| 102 | VA FORM 10-10F
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| 103 | DEPARTMENT OF VETERANS AFFAIRS
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| 104 | FINANCIAL WORKSHEET
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| 105 | THE LAW PROVIDES SEVERE PENALTIES FOR WILLFUL SUBMISSION OF FALSE INFORMATION
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| 106 | SEE PAGE 3 FOR PRIVACY ACT AND PAPERWORK REDUCTION ACT INFORMATION
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| 107 | Applicant's Name:
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| 108 | | Social Security Number:
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| 109 | A. Marital Status
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| 110 | 1. Were you married last calendar year.
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| 111 | | 2. Did you live with your spouse
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| 112 | | 3. If you did not live with your spouse, show the
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| 113 | , go to Section B).
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| 114 | | last calendar year. (If
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| 115 | | amount you contributed to your spouse's support
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| 116 | | to Section B).
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| 117 | | last calendar year
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| 118 | B. Dependent Children
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| 119 | During last calendar year, did you have any UNMARRIED children or stepchildren who are under the age of 18 or between the ages
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| 120 | of 18 and 23 and attending school? OR did you have any unmarried children over the age of 17 who became permanently incapable
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| 121 | of self-support before reaching the age of 18?
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| 122 | , go to Section C)
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| 123 | Child's Name
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| 124 | | Did the child
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| 125 | | Did you contribute
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| 126 | | Did the
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| 127 | | Was the child's
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| 128 | | incapable of
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| 129 | | live with you
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| 130 | | to the child's
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| 131 | | child have
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| 132 | | income available
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| 133 | | any income?
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| 134 | | to you?
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| 135 | C. Previous Calendar Year Gross Income for
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| 136 | (including amounts deducted for taxes, insurance, Medicare, etc.)
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| 137 | Type of Income
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| 138 | 1. Social Security (Not SSI)
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| 139 | 2. U.S. Civil Service
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| 140 | 3. U.S. Railroad Retirement
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| 141 | 4. Military Retirement
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| 142 | 5. Unemployment Compensation
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| 143 | 6. Other Retirement (Company, state, local, etc.)
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| 144 | 7. Total Income from Employment
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| 145 | 8. Interest, Dividend, or Annuity Income
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| 146 | 9. Workers Compensation or Black Lung Benefits
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| 147 | 10. All Other Income
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| 148 | 11. Total Income
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| 149 | E. Previous Calendar Year Net Worth
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| 150 | Type of Asset
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| 151 | 1. Cash, Amounts in Bank Accounts (Include IRA's)
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| 152 | 2. Stocks and Bonds
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| 153 | 3. Real Property (Not including your primary residence)
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| 154 | (market value of property minus incumbrances)
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| 155 | 4. Other Property or Assets not Shown Elsewhere
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| 156 | 5. Debts (Include any debts that will reduce the value
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| 157 | of property listed in E4)(Cannot exceed E4)
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| 158 | 6. Net Worth (Line E1 + E2 + E3 + E4 minus line E5)
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| 159 | 7. TOTAL (Add items D(11) and E(6))
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| 160 | D. Deductible Expenses
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| 161 | 1. List medical expenses ACTUALLY paid by you during the previous calendar year
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| 162 | (include Medicare and other health insurance expenses).
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| 163 | 2. List amounts paid by you during the previous calendar year for funeral and burial expenses
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| 164 | of a deceased spouse or child.
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| 165 | 3. List amounts paid by you during the previous calendar year for YOUR educational expenses.
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| 166 | (Do NOT show spouse's or children's payments)
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| 167 | 4. Was employment income reported for a child in item C7
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| 168 | | FOR VA USE ONLY
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| 169 | | 5. Enter child's income exclusion
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| 170 | 6. List each child for whom employment income was reported in item C7.
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| 171 | | Exclusion from
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| 172 | | income from
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| 173 | | employment income
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| 174 | | and enter
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| 175 | | education expenses
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| 176 | TO BE COMPLETED BY VA (VETERANS AFFAIRS)
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| 177 | 7. Child's Reported Employment Income (Item D6(B) above)
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| 178 | 8. Child's Countable Employment Income (Item D6(F) above)
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| 179 | 9. Child's Employment Income Exclusion (Subtract Item D8 from Item D7))
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| 180 | 10. Total Deductible Expenses (Add Items D1, D2, D3 and D9)
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| 181 | 11. Attributable Income (Subtract Item D10 from C11)
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| 182 | Completion of this form with signature of veteran is certification
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| 183 | that the veteran has received a copy of the privacy act statement.
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| 184 | THE ABOVE INFORMATION IS CORRECT
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| 185 | | Signature of Veteran or Designee
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| 186 | TO THE BEST OF MY KNOWLEDGE.
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| 187 | F. TO BE COMPLETED BY DISCRETIONARY VETERANS WHO
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| 188 | ARE REQUIRED TO MAKE COPAYMENTS
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| 189 | Eligibility Category
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| 190 | | Veterans in Category C must agree to pay VA a Deductible not to exceed the Medicare
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| 191 | | Deductible plus a per diem for Hospital and Nursing Home care. A per Visit
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| 192 | | Deductible is required for Category C Veterans to receive Outpatient care.
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| 193 | | The Billing Period and Rates are specified in 38 U.S.C.
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| 194 | I AGREE TO PAY THE VA THE APPLICABLE
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| 195 | DEDUCTIBLE FOR MY MEDICAL CARE.
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| 196 | HAS NOT AGREED
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| 197 | Special Note(s):
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| 198 | This means test was administered by the
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| 199 | Patient's means test is Pending Adjudication.
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| 200 | Patient's means test is No Longer Required.
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| 201 | Patient has declined to provide income information.
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| 202 | Previous years thresholds were used to determine the patient's eligibility for care.
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| 203 | The means test must be re-applied once the correct thresholds are available.
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| 204 | Patient's annual income does not match the income associated with the means test.
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| 205 | Please edit and complete the means test again.
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| 206 | Copay Exemption Test Status is:
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| 207 | NON-EXEMPT
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| 208 | NO LONGER APPLICABLE
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| 209 | PENDING ADJUDICATION
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| 210 | MEANS TEST REQUIRED
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| 211 | CURRENT MEANS TEST STATUS IS
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| 212 | MEANS TEST NO LONGER REQUIRED
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| 213 | MEANS TEST EVENT DRIVER
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| 214 | Entry with an IEN OF
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| 215 | missing from
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| 216 | the ELIGIBILITY CODE file (#8)
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| 217 | ELIGIBILITY CODE file (#8) entry with an IEN OF
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| 218 | have a valid pointer to the MAS ELIGIBILITY CODE file (#8.1)
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| 219 | This Rx Copay Test was automatically created based on a completed means test
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| 220 | which was changed to NO LONGER REQUIRED. All data including income
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| 221 | screening was copied from the test on
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| 222 | LTC copay exemption test. All data including income screening
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| 223 | was copied from the test on
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| 224 | COMMENTS(
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| 225 | Patient
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| 226 | has an invalid secondary eligibility
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| 227 | PIMS PACKAGE
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| 228 | On
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| 229 | has an invalid secondary eligibility
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| 230 | XMY(
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| 231 | MAILMAN MSG FOR INVALID ELIGIBILITY CODE FILE ENTRIES
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| 232 | Means Test Required
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| 233 | DGBUL(
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| 234 | Action was taken on the following appointment out and the patient 'REQUIRES' a means test.
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| 235 | Patient ID:
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| 236 | Appointment:
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| 237 | Entered By:
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| 238 | Entered On:
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| 239 | Patient Relation cannot be setup for patient.
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| 240 | Individual Annual Income cannot be setup for patient.
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| 241 | Means Test Thresholds are not defined.
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| 242 | Please contact your site manager.
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| 243 | Do you wish to edit the
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| 244 | copay exemption
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| 245 | Veteran
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| 246 | Spouse
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| 247 | Children
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| 248 | Social Security (Not SSI)
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| 249 | U.S. Civil Service
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| 250 | U.S. Railroad Retirement
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| 251 | Military Retirement
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| 252 | Unemployment Compensation
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| 253 | Other Retirement
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| 254 | Total Employment Income
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| 255 | Interest,Dividend,Annuity
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| 256 | Workers Comp or Black Lung
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| 257 | All Other Income
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| 258 | Total -->
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| 259 | Medical Expenses:
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| 260 | Funeral and Burial Expenses:
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| 261 | Veteran's Educational Expenses:
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| 262 | Child's Education Expenses:
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| 263 | Enter: R to REDISPLAY information on dependent children
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| 264 | to edit information for the child listed after that number
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| 265 | Enter CHOICE:
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| 266 | Post-secondary education expenses are not applicable for this child.
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| 267 | Child's
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| 268 | Employment
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| 269 | Post-secondary
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| 270 | First Name
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| 271 | Income
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| 272 | Education Expenses
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| 273 | Income Thresholds:
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| 274 | MT Threshold:
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| 275 | GMT Threshold:
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| 276 | *Previous Years Thresholds*
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| 277 | Cash, Amts in Bank Accts
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| 278 | Stocks and Bonds
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| 279 | Real Property
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| 280 | Other Property or Assets
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| 281 | Debts
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| 282 | Declines to give income information makes a MT COPAY REQUIRED status.
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| 283 | Source of Test is IVM
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| 284 | Income of
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| 285 | with property of
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| 286 | MT COPAY REQUIRED status.
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| 287 | requires property information.
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| 288 | Requires property information.
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| 289 | test cannot be completed.
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| 290 | ...means test status is
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| 291 | ...copay test status is
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| 292 | Do you wish to complete the
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| 293 | NOTE: If you do not complete the LTC copay exemption test, the incomplete test
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| 294 | will be deleted.
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| 295 | Do you wish to complete the copay exemption test
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| 296 | DECLINES TO GIVE INCOME INFORMATION
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| 297 | Marital section must be completed.
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| 298 | Married is 'YES'. An active spouse for this means test does not exist.
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| 299 | An active spouse exists for this means test. Married should be 'YES'.
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| 300 | Dependent Children section must be completed.
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| 301 | Dependent Children is 'YES'. No active children exist.
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| 302 | A status of
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| 303 | #################### #################### ####################
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| 304 | #################### #################### ####################
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| 305 | #################### #################### ####################
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| 306 | #################### #################### ####################
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| 307 | #################### #################### ####################
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