| 1 | English French  Notes   Complete/Exclude
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| 2 | Y - If you want to purge data.                  
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| 3 | N - If you don't wish to purge data.                    
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| 4 | Purge patients not seen since:                          
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| 5 | SELECT A DATE IN THE PAST PLEASE!!                      
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| 6 | I'm going to purge all patients from the INCONSISTENT DATA file who haven't been                        
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| 7 | admitted or registered since                    
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| 8 | Is this correct                 
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| 9 | Y - To start the purge process.                 
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| 10 | N - To QUIT.                    
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| 11 | Generate a listing of inconsistent data elements by:                    
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| 12 | CHOOSE OUTPUT METHOD OR ENTER '^' TO QUIT:                      
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| 13 | The available choices are:                      
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| 14 |      Go To                      
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| 15 | List by (N)ame or (T)erminal Digit:                     
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| 16 | N - To generate listing in Alphabetical Order                   
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| 17 | T - To generate listing in Terminal Digit Order.                        
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| 18 | THIS OUTPUT REQUIRES 132 COLUMN OUTPUT                  
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| 19 | INCONSISTENT ELEMENTS FOR PATIENTS WITH A                       
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| 20 | Missing                 
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| 21 | Last Day                        
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| 22 | Home Phone #                    
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| 23 | Soc Sec #                       
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| 24 | ID'ed                   
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| 25 | Edited by                       
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| 26 | Inconsistent/Missing Data Elements                      
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| 27 | TABLE OF INCONSISTENT/MISSING DATA ELEMENTS                     
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| 28 | UNIDENTIFIED PATIENT #                  
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| 29 | Do you want to delete the existing entries and rebuild the file                 
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| 30 | Y - If you want to remove all existing entries from the INCONSISTENT DATA                       
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| 31 | file and rebuild from scratch.                  
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| 32 | N - If you just want to add newly identified inconsistencies to the                     
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| 33 | existing file.                  
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| 34 | Rebuild for patients seen since what date:                      
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| 35 | I'm going to check all patients who were admitted or registered on or after                     
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| 36 |  [Within the Past                       
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| 37 | DELETE all existing entries prior to rebuilding                 
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| 38 | add any new inconsistent data elements to the existing file                     
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| 39 | Y - If this is what you want to do.                     
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| 40 | N - If you wish to STOP processing and reconsider this action.                  
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| 41 | INCONSISTENT DATA^38.5P^^0                      
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| 42 | ' OPTION RUNNING FROM                   
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| 43 | UNABLE TO RUN THIS OPTION AT CURRENT TIME!!                     
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| 44 | Do you really want to update existing inconsistent entries                      
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| 45 | Y - If you want me to run through all the entries currently filed in                    
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| 46 | the INCONSISTENT DATA file and verify they're still inconsistent.                       
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| 47 | N - If you wish to QUIT and rethink this action.                        
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| 48 | This check can not be edited.  It is automatically turned                       
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| 49 | Temporary:                      
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| 50 | POS:                    
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| 51 | Claim #:                        
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| 52 | Relig:                  
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| 53 | Ethnicity:                      
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| 54 | Primary Eligibility:                    
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| 55 | PENDING REVERIFICATION                  
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| 56 | Other Eligibilities:                    
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| 57 | Confidential Address:                   
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| 58 | From/To: NOT APPLICABLE                 
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| 59 | From/To:                        
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| 60 | COORDINATING MASTER OF RECORD:                  
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| 61 | Scheduled Admit                 
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| 62 |  for treating specialty                         
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| 63 | Currently enrolled in                   
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| 64 | Future Appointments:                    
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| 65 | See Scheduling options for additional appointments.                     
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| 66 |  * NO ACTION TAKEN *                    
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| 67 | Press RETURN to CONTINUE:                       
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| 68 | Catastrophically Disabled Review Date:                  
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| 69 |  Primary Elig. Code:                    
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| 70 | Other Elig. Code(s):                    
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| 71 |   Service Connected: NO                 
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| 72 |          SC Percent:                    
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| 73 | NOT A VETERAN                   
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| 74 |     Health Insurance:                   
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| 75 | Medicaid Elig:                  
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| 76 |   Means Test Status:  NOT IN MEANS TEST FILE                    
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| 77 |   Invalid pseudo SSN.                   
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| 78 | Type 'P' for the valid one                      
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| 79 | Pseudo SSN adjusted to match edited name value ==>                      
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| 80 | VERIFY FIELDS                   
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| 81 |   Already used by patient '                     
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| 82 |   The SSN must not begin with 9.                        
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| 83 |    First three digits cannot be zeros.                  
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| 84 |       Note: This is a RR Retirement SSN.                        
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| 85 |       Note: This is a Test Patient SSN.                 
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| 86 |  Collateral of                  
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| 87 | Must have same SSN to be collateral                     
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| 88 | Has collateral                  
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| 89 |  be sure to change SSN                  
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| 90 | The date of birth is too early for the selected category of beneficiary                 
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| 91 | Make another selection or correct the date of birth.                    
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| 92 | The date of birth is too late for the selected category of beneficiary.                 
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| 93 | The patient's age is too young for the selected category of beneficiary.                        
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| 94 | This service entry date would make the patient too young for service.                   
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| 95 | DOB                     
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| 96 | Previous service entry date is not on file                      
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| 97 | This service entry date must be before than the first service entry date                        
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| 98 | This service entry date must be less than the second service entry date                         
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| 99 | The service separation date must be after the entry date                        
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| 100 | This service separation date must be before the next service entry date                         
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| 101 | The service separation date must be before the next service entry date                  
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| 102 | **NOTE-Change(s) made in this session deleted the veteran's Combat Vet status!                  
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| 103 | But I need a Start Date for this Temporary Address.                     
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| 104 | But I need at least one line of a Temporary address.                    
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| 105 | But I need a Start Date.                        
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| 106 | But I need at least one active category.                        
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| 107 | I need at least one line of Address.                    
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| 108 | But I need to know where you were treated most recently.                        
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| 109 | Patient is not a veteran.  Can't enter rated disabilities                       
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| 110 | SPOUSE'S                        
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| 111 | DEPENDENT'S                     
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| 112 | CHILD'S                         
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| 113 | Incomplete Entry...Deleted                      
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| 114 | No dependents to inactivate!                    
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| 115 | Enter a number 1-                       
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| 116 |  to indicate the dependent you wish to inactivate:                      
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| 117 |  indicating the number of the dependent you wish to inactivate                  
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| 118 | RELATIONSHIP:                   
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| 119 | Entry incomplete...deleted                      
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| 120 | Dependent has been inactivated as of                    
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| 121 | Date                    
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| 122 |  no longer a dependent                  
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| 123 | Enter the date this person was no longer a dependent of the veteran.                    
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| 124 | This could include a date of death or the date a child turned 18 for                    
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| 125 | children.  For a spouse, this would be the date of divorce or date                      
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| 126 | of death of the spouse.  Date must be after the person became a                 
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| 127 | dependent, but prior to 12/31/                  
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| 128 | A person should only be inactivated if the individual was not a                 
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| 129 | dependent at any time during the prior calendar year.                   
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| 130 | A spouse should be inactivated if the spouse and veteran were not                       
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| 131 | married as of 12/31/                    
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| 132 | Warning: Data will be used if dependent was active at least one day in a                        
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| 133 | year.  Data will not be used if inactivation is prior to 1/1/                   
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| 134 |  or it                  
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| 135 | is equal to the activation date.                        
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| 136 | Do you wish to inactivate this dependent on the selected date?                  
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| 137 |     [Must edit through means test!!]                    
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| 138 | EFFECTIVE DATE                  
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| 139 | Please return to screen 8 and check the veteran's effective date.                       
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| 140 | The effective date was created based on the veteran's date of birth.                    
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| 141 | You might also want to check the date of birth for this veteran.                        
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| 142 | This dependent is 18 years or older.  To list this person as a dependent                        
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| 143 | they have to be:                        
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| 144 |      1.  An UNMARRIED child who is under the age of 18.                 
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| 145 |      2.  Between the ages of 18 and 23 and attending school.                    
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| 146 |      3.  An unmarried child over the age of 17 who became permanently                   
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| 147 |          incapable of self support before the age of 18.                        
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| 148 | Use 'Expand Dependent' option to change effective date.                 
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| 149 | Enter the date this person first became a dependent of the veteran.                     
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| 150 | In the case of a spouse, this would be the date of marriage.  For                       
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| 151 | a parent or other dependent, this would be the date the dependent                       
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| 152 | moved in.  For a child, this would be the date of birth or date of                      
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| 153 | Date must be before DEC 31,                     
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| 154 |  as dependents are collected for the                    
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| 155 | prior calendar year only.                       
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| 156 | Enter '^' to stop the display                   
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| 157 | and edit                        
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| 158 | of data, '^N' to jump to screen #N (see                 
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| 159 | listing below), <RET> to continue on to the next available screen                       
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| 160 |  or enter                       
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| 161 | the field group number(s) you wish to edit using commas and dashes as                   
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| 162 | delimiters.  Those groups enclosed in brackets                  
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| 163 |  are editable while those                       
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| 164 | enclosed in arrows                      
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| 165 |  are not.                       
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| 166 |   Enter 'ALL' to edit all editable data                 
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| 167 | elements on the screen.                 
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| 168 | You may precede your selection with 'V' to denote veteran.                      
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| 169 | DATA GROUPS ON SCREEN                   
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| 170 | Press RETURN key                        
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| 171 |  to EXIT Screen                         
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| 172 | TO EXIT                 
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| 173 | Name, SSN, DOB^Alias Name & SSN (if applicable)^Remarks concerning this patient^Home Address, Phone & Work Phone^Temporary Address, Dates, Phone                        
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| 174 | Confidential Address,Dates and Types                    
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| 175 | Sex, POB, Parents, etc.^Dates/Locations of Previous Care^Race and Ethnicity                     
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| 176 | Primary Next-of-Kin^Secondary Next-of-Kin^Primary Emergency Contact^Secondary Emergency Contact^Designee to receive personal effects                    
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| 177 | Applicant Employer, Address^Spouses Employer, Address                   
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| 178 | Unexpired Insurance Policies^Eligibile for Medicaid                     
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| 179 | Service History^Prisoner of War^Combat^Vietnam Service^Agent Orange Exposure^IONizing Radiation Exposure^                       
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| 180 | Lebanon Service^Grenada Service^Panama Service^Persian Gulf Service^Somalia Service^Environmental Contaminants Exposure^Military Retirement/Disability^Dental History^Yugoslavia Service^Purple Heart Recipient^                        
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| 181 | Nose/Throat Radium Treatment                    
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| 182 | Patient Type, SC Data, Claim Info^VA Monetary Benefits^POS, Eligibility Code(s)^SC Conditions relayed by applicant                      
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| 183 | Spouse's Demographic Info^Dependents' Demographic Info                  
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| 184 | Social Security^U.S. Civil Service^U.S. Railroad Retirement^Military Retirement^Unemployment^Other Retirement^Total Employment Income^Interest,Dividend,Annuity^Workers Comp or Black Lung^Other Income                 
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| 185 | Ineligible Patient Information^Missing Patient Information                      
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| 186 | Eligibility Verification^Monetary Benefits Verification^Service Record Verification^Rated Disabilities (VA)                     
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| 187 | Four most recent admission episodes on file for this applicant are displayed                    
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| 188 | in inverse order.                       
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| 189 | Four most recent applications for care (registrations) are displayed in                 
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| 190 | inverse order.                  
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| 191 | Clinics in which actively enrolled^Pending (future) appointments                        
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| 192 | Sponsor information is displayed for patients.                  
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| 193 | Demographic^Confidential Address^Patient^Contact^Employment^Insurance^Service Record^Eligibility^Family Demographic^Income Screening^Missing/Ineligible^Eligibility Verification^                       
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| 194 | Admission Info^Application Info^Appointment Info^Sponsor Demograhics                    
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| 195 | Enter your division:                    
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| 196 | Unable to update Purple Heart Data.                     
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| 197 | Unable to update Purple Heart History.                  
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| 198 | =ENTER new                      
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| 199 |  to EDIT,                       
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| 200 |  for screen N or                        
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| 201 |  to QUIT                        
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| 202 |   COPYING will move Family Demographic and Income Data into the next year...                    
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| 203 |    YOU HAVE ALREADY MODIFIED CURRENT YEAR DEPENDENT INFORMATION                 
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| 204 |      COPYING will OVERWRITE this modified dependent information                 
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| 205 |      with LAST year's data -  ** Please review dependent data **                        
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| 206 |    ...FAMILY DEMOGRAPHIC DATA COPIED                    
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| 207 |    ...............INCOME DATA COPIED                    
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| 208 | ===> Record has been classified as sensitive.                   
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| 209 | Your MAS PARAMETER file is not properly set up!                 
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| 210 | LOCAL REGISTRATION QUESTIONS                    
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| 211 | INVALID SCREEN NUMBER...VALID SCREENS ARE                       
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| 212 | (To edit only veteran income, precede selection with 'V' [ex. 'V1-3']                   
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| 213 | precede with 'S' to edit spouse                 
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| 214 | precede with 'D' to edit dependents                     
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| 215 | >>> Patient cannot be registered while there is still an open disposition.                      
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| 216 | Patient: Eligibility, Demographic                       
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| 217 |    Emergency Contact and Military Service                       
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| 218 | Marital                 
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| 219 | Another user is editing, try later...                   
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| 220 | Insurance                       
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| 221 | HINQ Inquiry                    
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| 222 | Consistency Checker                     
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| 223 | At this time you may Register the patient if he or she is present and                   
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| 224 | seeking care.  Answer 'No' if this was a mail-in application.                   
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| 225 | Would you like to Register the patient                  
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| 226 | Exit Interview                  
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| 227 | PRINT 10/10T                    
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| 228 | DGRPT 10-10T REGISTRATION                       
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| 229 | Patient Demographics                    
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| 230 | Permanent Address:                      
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| 231 | Emergency Contact                       
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| 232 | NOK:                    
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| 233 | Military Service                        
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| 234 | Service Branch [Last]:                  
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| 235 | Number [Last]:                  
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| 236 | Purple Heart:                   
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| 237 | Eligibility                     
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| 238 | Patient Type:                   
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| 239 | Primary Elig Code:                      
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| 240 | Marital/Spouse                  
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| 241 | Spouse's Name:                  
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| 242 | Last Year's Estimated                   
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| 243 | Covered by Health Insurance:                    
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| 244 | Insurance Co.      Subscriber ID     Group       Holder  Effective Expires                      
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| 245 | PRINT 10-10T                    
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| 246 |  - FROM REGISTRATION                    
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| 247 | Reg Date/Time:                  
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| 248 | AUTOMATED VA FORM 10-10T                        
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| 249 | VA FORM 10-10T                  
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| 250 | |2. Social Security Number                      
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| 251 | |3. Date of Birth                       
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| 252 | 4A. Applicant's Mailing Street Address                  
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| 253 | |4D. Zip Code                   
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| 254 | |6. Home Telephone Number                       
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| 255 | |7. Work Telephone Number                       
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| 256 | 8A. Emergency Contact                   
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| 257 | |8C. Home Telephone Number                      
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| 258 | |8D. Work Telephone Number                      
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| 259 | 8E. Mailing Address of Emergency Contact                        
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| 260 | |9. Is Emergency Contact                        
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| 261 | |Also Next of Kin                       
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| 262 | 10. Benefit Applying For:                       
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| 263 | HOSPITAL/OUTPATIENT TREATMENT                   
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| 264 | 11. Applicant Status:                   
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| 265 | A. Service Connected                    
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| 266 | |B. Prisoner of War                     
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| 267 | |C. Aid and Attendance                  
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| 268 | |D. Military Disability Retired                 
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| 269 | E. VA Pension                   
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| 270 | |F. Primary Eligibility Code                    
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| 271 | |G. Other Eligibility Code                      
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| 272 | |H. Purple Heart Recipient                      
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| 273 | 12. Exposure To:                        
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| 274 | |A. Agent Orange                        
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| 275 | |C. Environmental Contaminants                  
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| 276 | 13. Medical Care Related To:                    
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| 277 | 14A. Do You Have Health Coverage                        
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| 278 | |14B. Name of Health Insurance Carrier                  
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| 279 | 15. Branch of Service                   
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| 280 | |16. Latest Service Number                      
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| 281 | |17. Marital Status                     
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| 282 | |18B. Spouse's Social Security Number                   
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| 283 | 18C. Year of Marriage                   
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| 284 | |18D. Number of Dependents                      
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| 285 | |19. Last Year's Estimated                      
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| 286 |  Taxable Income                 
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| 287 | Consent To Release Information: I hereby authorize the Department of Veterans Affairs to disclose any such history, diagnostic and                      
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| 288 | treatment information from my medical records (including information relating to the diagnosis, treatment or other therapy for the                      
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| 289 | conditions of drug abuse, alcoholism or alcohol abuse, sickle cell anemia, or testing for or infection with the human                   
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| 290 | immunodeficiency virus) to the carrier or contractor of any health plan contract under which I am apparently entitled to medical                        
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| 291 | care or payment of the expense of care that is identified above, as considered necessary by VA representatives for the discharge                        
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| 292 | of the legal or contractual obligations of the insurer or other party against whom liability is asserted.  I understand that I                  
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| 293 | may revoke this authorization at any time, except to the extent that action has already been taken in reliance on it.  Without my                       
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| 294 | express revocation, this consent will automatically expire when all action arising from VA's claim for reimbursement for my                     
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| 295 | medical care has been completed.                        
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| 296 | Co-payment Notice: If your household income exceeds the established threshold, you will be considered                   
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| 297 | Discretionary                   
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| 298 | Such veterans must pay a co-payment not to exceed the Medicare deductible, plus a per diem for hospital and nursing care.                       
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| 299 | By signing this application, you are agreeing to pay the VA the applicable co-payment if you are determined to be a                     
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| 300 | Signature of Applicant                  
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| 301 | Public reporting burden for this collection of information is estimated to average 10 minutes per response, including the time for                      
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| 302 | reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the                    
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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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