English	French	Notes	Complete/Exclude
WARNING:  You are about to access a means test for which a hardship has			
          been authorized.  If you proceed, the hardship will be removed			
          and the means test category will be recalculated!  To avoid			
          this problem, enter NO at the next prompt and use the 'View			
          a Past Means Test' option should you need to see details of			
          this means test.			
Enter NO to stop editing this means test.  Enter YES to continue			
Do you want to continue editing this means test?  			
Last means test is not PENDING ADJUDICATION.			
Patient pending adjudication for 			
Last means test is not REQUIRED.			
No means test to change.			
MEANS TEST DATE: 			
SOURCE OF TEST: 			
CATEGORY A			
DG MEANS TEST EVENTS			
HARDSHIP?			
CURRENT STATUS			
TEST DATE			
CTGRY CHNGD BY			
DT/TM CTGRY CHNGD			
TEST STATUS			
A Hardship has been granted for 			
Only the site granting the Hardship may edit it.			
Please, contact 			
 to edit the record.			
Enter <RETURN> to continue.			
DGMTH HARDSHIP			
Hardship			
Current Means Test Status:   			
Income Year:   			
Means Test Date:   			
Agreed To Pay Deductible:   			
Hardship?:   			
Hardship Effective Date:   			
Site Granting Hardship:   			
Approved By:   			
Hardship Reason:   			
Date Category Last Changed:   			
Category Last Changed By:   			
COMMENTS:			
YOUR DUZ IS NOT DEFINED!			
PATIENT NOT CURRENTLY RESPONSIBLE FOR COPAYMENT CHARGES!			
AN ERROR OCCURRED - 			
Pr^408.32:EMZ			
Means Test Status			
Hardship Effective Date			
Hardship Review Date			
Enter a future date if you wish to conduct a review.			
Hardship Reason			
Are you sure that the hardship should be deleted			
Means Test Menu Options^1N^			
   Future dates are not allowed.			
Select    Ending Date: 			
Beginning Date must be prior to Ending Date			
Agreed to Pay Deductible Listing			
NO ACTIVE PATIENTS WHO HAVE NOT AGREED TO PAY DEDUCTIBLE			
Pend Adj			
Cat. C			
Active Patients Who Have Not Agreed To Pay Deductible			
ACTIVE= Sched. Admissions, Dispositions, Pt. Movements, or Clinic Appts.			
INHOUSE = Current Inpatient			
PAST    = 			
FUTURE  = After 			
Future Appt. w/ Means Test			
VAUTC(			
VAUTD(			
Do you want to generate letters			
Enter 'Y'es to generate letters from the listing or			
Enter 'N'o to produce the listing, but not the letters.			
THERE ARE NO PATIENTS THAT WILL NEED A 			
 TEST AT THEIR NEXT APPOINTMENT FOR THIS DATE RANGE			
PEND. ADJ.			
Patients Requiring Means Test At Next Appointment			
Copay Exemptions That Will Need Updating At Next Appointment			
PATIENT ID			
APPT DATE/TIME			
No review dates found between selected date range.			
Hardship Review Date(s)			
 Patient ID 			
Review Date			
Hardship Review Output			
Previous Year Threshold Output			
Means Test Using Previous Years Threshold			
Date of Test			
NO MEANS TEST WITH PREVIOUS YEARS THRESHOLD			
 TEST STATUS NAME: 			
DGCAT#^DGBEG^DGEND^DGMTYPT			
 TEST STATUS Report			
STATUS:  			
No patients found with 			
 test status of 			
No patients found for requested date range.			
Date of			
Pend. Adj.			
Source			
Test			
Date of Test: 			
Completion Date/time: 			
By: 			
VA FORM 10-10F			
DEPARTMENT OF VETERANS AFFAIRS			
FINANCIAL WORKSHEET			
THE LAW PROVIDES SEVERE PENALTIES FOR WILLFUL SUBMISSION OF FALSE INFORMATION			
SEE PAGE 3 FOR PRIVACY ACT AND PAPERWORK REDUCTION ACT INFORMATION			
Applicant's Name:  			
| Social Security Number:  			
A. Marital Status			
1. Were you married last calendar year.			
| 2. Did you live with your spouse			
| 3. If you did not live with your spouse, show the			
, go to Section B).			
| last calendar year. (If 			
| amount you contributed to your spouse's support			
| to Section B).    			
| last calendar year    			
B. Dependent Children			
During last calendar year, did you have any UNMARRIED children or stepchildren who are under the age of 18 or between the ages			
of 18 and 23 and attending school?  OR did you have any unmarried children over the age of 17 who became permanently incapable			
of self-support before reaching the age of 18?    			
, go to Section C)			
Child's Name			
| Did the child			
| Did you contribute			
| Did the			
| Was the child's			
| incapable of			
| live with you			
| to the child's			
| child have			
| income available			
| any income?			
| to you?			
C. Previous Calendar Year Gross Income for 			
  (including amounts deducted for taxes, insurance, Medicare, etc.)			
Type of Income			
1. Social Security (Not SSI)			
2. U.S. Civil Service			
3. U.S. Railroad Retirement			
4. Military Retirement			
5. Unemployment Compensation			
6. Other Retirement (Company, state, local, etc.)			
7. Total Income from Employment			
8. Interest, Dividend, or Annuity Income			
9. Workers Compensation or Black Lung Benefits			
10. All Other Income			
11. Total Income			
E. Previous Calendar Year Net Worth			
Type of Asset			
1. Cash, Amounts in Bank Accounts (Include IRA's)			
2. Stocks and Bonds			
3. Real Property (Not including your primary residence)			
(market value of property minus incumbrances)			
4. Other Property or Assets not Shown Elsewhere			
5. Debts (Include any debts that will reduce the value			
of property listed in E4)(Cannot exceed E4)			
6. Net Worth (Line E1 + E2 + E3 + E4 minus line E5)			
7. TOTAL (Add items D(11) and E(6))			
D. Deductible Expenses			
1. List medical expenses ACTUALLY paid by you during the previous calendar year			
(include Medicare and other health insurance expenses).    			
2. List amounts paid by you during the previous calendar year for funeral and burial expenses			
of a deceased spouse or child.    			
3. List amounts paid by you during the previous calendar year for YOUR educational expenses.			
(Do NOT show spouse's or children's payments)    			
4. Was employment income reported for a child in item C7			
|     FOR VA USE ONLY			
| 5. Enter child's income exclusion			
6. List each child for whom employment income was reported in item C7.			
| Exclusion from			
| income from			
| employment income			
| and enter 			
| education expenses			
TO BE COMPLETED BY VA (VETERANS AFFAIRS)			
7. Child's Reported Employment Income (Item D6(B) above)			
8. Child's Countable Employment Income (Item D6(F) above)			
9. Child's Employment Income Exclusion (Subtract Item D8 from Item D7))			
10. Total Deductible Expenses (Add Items D1, D2, D3 and D9)			
11. Attributable Income (Subtract Item D10 from C11)			
Completion of this form with signature of veteran is certification			
that the veteran has received a copy of the privacy act statement.			
THE ABOVE INFORMATION IS CORRECT			
| Signature of Veteran or Designee			
TO THE BEST OF MY KNOWLEDGE.			
F.  TO BE COMPLETED BY DISCRETIONARY VETERANS WHO			
ARE REQUIRED TO MAKE COPAYMENTS			
Eligibility Category			
| Veterans in Category C must agree to pay VA a Deductible not to exceed the Medicare			
| Deductible plus a per diem for Hospital and Nursing Home care.  A per Visit			
| Deductible is required for Category C Veterans to receive Outpatient care.			
| The Billing Period and Rates are specified in 38 U.S.C.			
I AGREE TO PAY THE VA THE APPLICABLE			
DEDUCTIBLE FOR MY MEDICAL CARE.			
HAS NOT AGREED			
Special Note(s):			
This means test was administered by the 			
Patient's means test is Pending Adjudication.			
Patient's means test is No Longer Required.			
Patient has declined to provide income information.			
Previous years thresholds were used to determine the patient's eligibility for care.			
The means test must be re-applied once the correct thresholds are available.			
Patient's annual income does not match the income associated with the means test.			
Please edit and complete the means test again.			
Copay Exemption Test Status is: 			
NON-EXEMPT			
NO LONGER APPLICABLE			
PENDING ADJUDICATION			
MEANS TEST REQUIRED			
CURRENT MEANS TEST STATUS IS 			
MEANS TEST NO LONGER REQUIRED			
MEANS TEST EVENT DRIVER			
Entry with an IEN OF 			
 missing from			
the ELIGIBILITY CODE file (#8)			
ELIGIBILITY CODE file (#8) entry with an IEN OF 			
have a valid pointer to the MAS ELIGIBILITY CODE file (#8.1)			
This Rx Copay Test was automatically created based on a completed means test			
which was changed to NO LONGER REQUIRED. All data including income			
screening was copied from the test on 			
LTC copay exemption test. All data including income screening			
was copied from the test on 			
COMMENTS(			
Patient 			
 has an invalid secondary eligibility			
PIMS PACKAGE			
On 			
has an invalid secondary eligibility			
XMY(			
MAILMAN MSG FOR INVALID ELIGIBILITY CODE FILE ENTRIES			
     Means Test Required			
DGBUL(			
Action was taken on the following appointment out and the patient 'REQUIRES' a means test.			
 Patient ID:  			
Appointment:  			
 Entered By:  			
 Entered On:  			
Patient Relation cannot be setup for patient.			
Individual Annual Income cannot be setup for patient.			
Means Test Thresholds are not defined.			
Please contact your site manager.			
Do you wish to edit the 			
copay exemption			
Veteran			
Spouse			
Children			
Social Security (Not SSI)			
U.S. Civil Service			
U.S. Railroad Retirement			
Military Retirement			
Unemployment Compensation			
Other Retirement			
Total Employment Income			
Interest,Dividend,Annuity			
Workers Comp or Black Lung			
All Other Income			
Total -->			
Medical Expenses: 			
Funeral and Burial Expenses: 			
Veteran's Educational Expenses: 			
 Child's Education Expenses: 			
Enter:  R to REDISPLAY information on dependent children			
 to edit information for the child listed after that number			
Enter CHOICE: 			
Post-secondary education expenses are not applicable for this child.			
Child's			
Employment			
Post-secondary			
First Name			
Income			
Education Expenses			
Income Thresholds:   			
MT Threshold: 			
GMT Threshold: 			
*Previous Years Thresholds*			
Cash, Amts in Bank Accts			
Stocks and Bonds			
Real Property			
Other Property or Assets			
Debts			
Declines to give income information makes a MT COPAY REQUIRED status.			
Source of Test is IVM			
Income of 			
with property of 			
MT COPAY REQUIRED status.			
 requires property information.			
Requires property information.			
 test cannot be completed.			
...means test status is 			
...copay test status is 			
Do you wish to complete the 			
NOTE: If you do not complete the LTC copay exemption test, the incomplete test			
will be deleted.			
Do you wish to complete the copay exemption test			
DECLINES TO GIVE INCOME INFORMATION			
Marital section must be completed.			
Married is 'YES'.  An active spouse for this means test does not exist.			
An active spouse exists for this means test. Married should be 'YES'.			
Dependent Children section must be completed.			
Dependent Children is 'YES'.  No active children exist.			
A status of 			
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