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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