| 1 | English French Notes Complete/Exclude
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| 2 | Elig. Code:
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| 3 | Amt.: $
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| 4 | House Bound:
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| 5 | Tot.Ann. VA Check Amt.: $
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| 6 | Amount Earned Annual Income (SPOUSE):
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| 7 | Amount of Annual Social Security (SPOUSE):
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| 8 | Type of other Annual Retirement (SPOUSE):
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| 9 | Amount of other Annual Retirement (SPOUSE):
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| 10 | Amount of other Annual Income (SPOUSE):
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| 11 | Amount of Earned Annual Income (PAYEE):
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| 12 | Amount Annual
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| 13 | Soc. Sec. (PAYEE):
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| 14 | Receiving Soc. Sec. (PAYEE):
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| 15 | Other Annual
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| 16 | Retirement (PAYEE):
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| 17 | Amount Other Annual
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| 18 | Income (PAYEE):
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| 19 | ****** HINQ Upload/edit ******
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| 20 | Verification screen only
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| 21 | Patient file
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| 22 | BIRLS ONLY
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| 23 | BIRLS/C&P
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| 24 | NOT UPDATED
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| 25 | HINQ Response
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| 26 | ** BIRLS indicates Patient is deceased.
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| 27 | ** VA Monetary Ben. Terminated - Means Test Required **
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| 28 | Man.ver.
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| 29 | Not issued
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| 30 | Pat. Type:
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| 31 | Elig. Stat.:
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| 32 | Vet. Y/N:
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| 33 | Stat. Date:
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| 34 | Disab. Ind.:
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| 35 | Elig. code:
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| 36 | WARNING: Error Indicators for
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| 37 | .. Alert found.
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| 38 | Screen
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| 39 | HINQ Update .
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| 40 | another request pending, alert cleared
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| 41 | This patient data is being edited by another user
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| 42 | Checking the alerts .
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| 43 | . need more changes
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| 44 | LOAD/EDIT Screen
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| 45 | SC D
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| 46 | HINQ has data not in patient file `
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| 47 | Patient file has data not in HINQ `
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| 48 | HINQ, Patient file are different `
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| 49 | Screen (
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| 50 | Do you wish to acknowledge inconsistencies and clear this Alert ?
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| 51 | If the patient file has data that should not be updated by HINQ, this Alert
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| 52 | can be acknowledged and cleared by entering 'Y'es. Otherwise, just continue
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| 53 | Press RETURN to continue,'Y'es to acknowledge, '^' to exit:
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| 54 | Alert will be cleared
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| 55 | Alerts have been cleared
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| 56 | 3-SC Disabilities
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| 57 | 3+SC Disabilities
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| 58 | Pension
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| 59 | Disability
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| 60 | 5?SC Combined %
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| 61 | SC LESS THAN
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| 62 | 2?Folder Location
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| 63 | 5?VA Check/Net Award
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| 64 | Entering a request in the HINQ suspense file...
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| 65 | Checking alert data
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| 66 | Clear corrected HINQ alerts
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| 67 | Clearing corrected HINQ alerts
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| 68 | No alerts cleared...
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| 69 | IOINHI;IOINLOW;IOBON;IOBOFF
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| 70 | Is this the patient to update (YES, NO, IGNORE, DISPLAY, ALERT)? YES//
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| 71 | You are not processing an Alert, 'A'lert update and display not available.
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| 72 | 'Y'es, Will continue with this patient
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| 73 | 'N'o, Go next patient
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| 74 | 'I'gnore, Patient will NOT appear in ALL option until reHINQ
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| 75 | 'D'isplay will show you the HINQ mail message.
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| 76 | 'A'lert, will update and display the Alert if processing alerts
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| 77 | '^' to quit
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| 78 | * This option will print out a report, identical to the mail *
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| 79 | * messages, of the patients in the suspense file with a *
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| 80 | * successful HINQ request. *
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| 81 | BIRLS only response and the 'Diagnostic Verified Indicator' is NO.
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| 82 | Verify SC at folder location:
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| 83 | No updating allowed.
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| 84 | Your version of MAS is NOT greater than 5.1, thus the Unemployable field
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| 85 | is not in your patient file. No uploading of this field allowed.
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| 86 | to CONTINUE,
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| 87 | to QUIT,
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| 88 | to update:
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| 89 | HINQ data does NOT seem right.
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| 90 | Data appears to be missing for
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| 91 | Please re-HINQ for this patient.
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| 92 | 30 days or greater
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| 93 | DVBWCHK...This init should run after PIMS v5.3 is installed
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| 94 | <<PROGRAMMER NOT DEFINED>>
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| 95 | *** Updating DISABILITY CONDITION file (#31)
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| 96 | per VA circular 21-95-2, dated Feb. 1, 1995
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| 97 | The Disability Condition file (31) update has finished.
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| 98 | disability codes were added.
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| 99 | 0-DAY LETTER
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| 100 | Updating '0-DAY LETTER' in the EAS MT LETTER File (#713.3)
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| 101 | According to our records you have not responded to our previous requests
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| 102 | to complete the financial section of VA Form 10-10EZ, Application for
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| 103 | Health Benefits. This is to inform you that your current financial
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| 104 | assessment (means test) has expired.
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| 105 | How Does This Affect Your Eligibility for Cost Free Care?
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| 106 | o We do not have a current means test for you on file as is required to
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| 107 | determine your eligibility for either cost-free care or reduced
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| 108 | inpatient copayments.
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| 109 | How Does This Affect Your Enrollment?
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| 110 | o We are unable to determine your priority for enrollment in the VA
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| 111 | health care system.
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| 112 | What Do You Need To Do?
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| 113 | o Complete, sign and return a new VA Form 10-10EZ, including the
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| 114 | financial section.
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| 115 | o Read the enclosed VA Form 4107VHA, Your Rights to Appeal our Decision.
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| 116 | If you disagree with our decision, you or your representative may
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| 117 | complete a Notice of Disagreement and return it to the Enrollment
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| 118 | Coordinator or Health Benefits Advisor at your local VA health care
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| 119 | What If You Have Questions?
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| 120 | DGNEW(
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| 121 | NOTE: An error occurred when updating the 0-DAY LETTER
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| 122 | Please contact the VistA Help Desk.
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| 123 | 30-DAY LETTER
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| 124 | Updating '30-DAY LETTER' in the EAS MT LETTER File (#713.3)
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| 125 | Each year VA requires most nonservice-connected veterans and 0% service-
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| 126 | connected veterans to complete a financial assessment (means test). Our
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| 127 | records show that your annual means test is due.
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| 128 | As of this date we have not received the updated financial income
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| 129 | information we requested in a previous letter.
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| 130 | What Does This Mean To You?
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| 131 | o An updated means test is needed to determine your ability to pay
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| 132 | copayments for your medical care and medications and your priority for
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| 133 | enrollment in the VA health care system.
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| 134 | o Failure to complete the means test by the anniversary date will cause
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| 135 | your priority for enrollment in the VA health care system to lapse.
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| 136 | o Complete and sign the enclosed Financial Assessment portion of the
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| 137 | enclosed VA Form 10-10EZ, Application for Health Benefits, reporting
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| 138 | income and assets for the previous calendar year.
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| 139 | o Return the completed and signed form in the enclosed envelope before
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| 140 | your means test anniversary date.
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| 141 | o When you report to your next health care appointment, bring your health
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| 142 | insurance card so we may update your health insurance information.
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| 143 | o Notify us if you feel you received this letter in error.
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| 144 | 60-DAY LETTER
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| 145 | Updating '60-DAY LETTER' in the EAS MT LETTER File (#713.3)
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| 146 | o Complete and sign the Financial Assessment portion of the enclosed VA
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| 147 | Form 10-10EZ, Application for Health Benefits, reporting income and
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| 148 | assets for the previous calendar year.
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| 149 | Pre-Installation Complete, the EAS MT Letters have been updated.
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| 150 | *** Updating EAS MT LETTERS file(#713.3)***
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| 151 | *** Updating 0-DAY LETTER ***
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| 152 | *** 0-DAY LETTER not updated ***
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| 153 | *** Updating 30-DAY LETTER ***
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| 154 | *** 30-DAY LETTER not updated ***
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| 155 | *** Updating 60-DAY LETTER ***
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| 156 | *** 60-DAY LETTER not updated ***
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| 157 | Pre-scan for un-flagged 0-day letters?
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| 158 | Pre-scan will provide the number of records which will have the 0-day
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| 159 | Flag-to-Print flag set to 'YES' when this routine is run in the conversion mode.
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| 160 | Enter 'YES' to pre-scan, 'NO' to convert the 0-day print flags
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| 161 | Beginning scan for un-flagged 0-day letters
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| 162 | records scanned
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| 163 | will have
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| 164 | the 0-day flag set to print
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| 165 | SITE
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| 166 | IS NOT A DCD PILOT SITE
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| 167 | POST-INSTALLATION COMPLETE
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| 168 | EAS*1*20 POST-INSTALL
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| 169 | EAS*1*20 POST INSTALL TASK #
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| 170 | QUEUED TO RUN
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| 171 | PATCH EAS*1*22 POST INSTALL
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| 172 | EAS MT LETTERS
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| 173 | Post-Install was not tasked off
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| 174 | Post-Install tasked: [
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| 175 | Post Install - EAS*1*22
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| 176 | G.EAS MTLETTERS
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| 177 | PATCH EAS-1-22
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| 178 | Entries were removed from the EAS MT LETTER STATUS File (#713.2)
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| 179 | which did not have a valid pointer to the EAS MT PATIENT STATUS
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| 180 | File (#713.1). The entries removed were for the processing dates
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| 181 | listed below. This is provided as information only.
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| 182 | Date Processed
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| 183 | Records Removed
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| 184 | The following patients in the EAS MT PATIENT STATUS File (#713.1)
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| 185 | do not have a corresponding entry in the EAS MT LETTER STATUS File (#713.2).
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| 186 | You can try re-generating the Means Test Letter dates for these
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| 187 | patients by running the REGEN procedure from the post-install
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| 188 | routine by entering 'D REGEN^EAS122PT' at the programmer prompt.
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| 189 | See the Patch Instructions for more details.
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| 190 | Re-generate Means Test Letter Dates for patients
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| 191 | identified in patch EAS*1*22 cleanup?
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| 192 | - Patient Merge Cleanup Process
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| 193 | - PATIENT MERGE CLEANUP
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| 194 | EAS*1.0*
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| 195 | : PATIENT MERGE CLEANUP - PROCESS STOPPED BY USER
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| 196 | : PATIENT MERGE CLEANUP - SUMMARY REPORT
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| 197 | EAS MT 30 DAY LETTER PRINT
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| 198 | ** Adding a new entry to LTC CO-PAY EXEMPTION file (#714.1).
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| 199 | LTC IS SERVICE RELATED - COMBAT VET ELIGIBLE
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| 200 | already exists in file #714.1.
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| 201 | not added to file #714.1
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| 202 | *** Updating LTC COPAY EXEMPTION (File #714.1) ***
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| 203 | - Modifying entry #11
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| 204 | ERROR: Entry #11 not updated
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| 205 | .01///LTC RELATED TO HOSPICE CARE
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| 206 | - Modifying entry #2
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| 207 | ERROR: Entry #2 not updated
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| 208 | .01///INCOME (LAST YEAR) BELOW LTC THRESHOLD
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| 209 | - Adding entry #12
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| 210 | INCOME (CURRENT YEAR) BELOW LTC THRESHOLD
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| 211 | The Post Install will now process through PATIENT (#2) file
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| 212 | to determine User Enrollee status for each Veteran by checking
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| 213 | inpatient/outpatient encounter for current fiscal year, any
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| 214 | future appointments and any fee basis authorizations.
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| 215 | EAS*1*25
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| 216 | USER ENROLLEE INITIAL DETERMINATION PROCESS
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| 217 | User Enrollee initial determination process was completed in previous run.
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| 218 | is currently running User Enrollee determination
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| 219 | process. Duplicate process cannot be started.
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| 220 | CURRENT IEN
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| 221 | by the user. Please restart the process by using the following
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| 222 | command at the programmer prompt:
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| 223 | Post install process for initial User Enrollee determination is completed.
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| 224 | GMTII - USER ENROLLEE INITIAL DETERMINATION PROCESS
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| 225 | NAIK.CHINTAN@FORUM.VA.GOV
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| 226 | Site Station number:
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| 227 | Site Name:
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| 228 | Process started at :
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| 229 | Process completed at :
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| 230 | Total Veterans processed :
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| 231 | Total Veterans with UE status:
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| 232 | PATIENT ADDRESS INQUIRY
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| 233 | *** Address could not be determined ***
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| 234 | *** No Address On File For This Patient ***
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| 235 | Patient Address:
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| 236 | UNKNOWN STREET ADDRESS
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| 237 | UNKNOWN CITY
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| 238 | UNKNOWN STATE
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| 239 | Bad Address Indicator:
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| 240 | Address Change Date:
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| 241 | Address Change Source:
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| 242 | Address Change Site:
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| 243 | LEGALLY SEPARATED
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| 244 | EXPENSE(408.21,
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| 245 | Answer Yes or No where applicable (Otherwise provide the requested information)
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| 246 | 3. Are You Eligible for Medicaid?
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| 247 | |3A. Are You Enrolled in Medicare Part A (Hospital Insurance)
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| 248 | |3B. Effective Date (If
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| 249 | 4. Are You Enrolled in Medicare Part B (Medical Insurance)
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| 250 | |4A. Effective Date (If
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| 251 | |4B. Medicare Claim Number
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| 252 | SECTION II - INSURANCE INFORMATION
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| 253 | 5. Are You Covered By Health Insurance (including coverage through a spouse)? (If
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| 254 | , provide the following information for
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| 255 | all insurance company(s) providing coverage to you.)
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| 256 | . Name of Insurance Company
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| 257 | A. Address of Insurance Company
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| 258 | B. Phone Number of Insurance Company
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| 259 | C. Name of Policy Holder
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| 260 | D. Relationship of Policy Holder
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| 261 | E. Policy Number
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| 262 | F. Group Name and/or Number
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| 263 | SECTION III - SPOUSE/DEPENDENT INFORMATION
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| 264 | 9. Current Marital Status
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| 265 | 9B. Spouse Residing in the Community?
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| 266 | |9C. Spouse's Social Security Number
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| 267 | 9A. Spouse Residing in the Community?
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| 268 | |9B. Spouse's Social Security Number
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| 269 | A. Dependent's Date of Birth
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| 270 | B. Dependent's Social Security Number
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| 271 | C. Dependent Residing in the Community?
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| 272 | We need to collect information regarding income, assets, and
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| 273 | expenses for you and your spouse. If you do not wish to provide this
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| 274 | information you must sign agreeing to make copayments and will
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| 275 | be charged the maximum copayment amount for all services. See the
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| 276 | top of page 2, read, sign, and date.
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| 277 | I do not wish to provide my detailed financial information.
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| 278 | I understand that I will be assessed the maximum copayment amount for
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| 279 | extended care services and agree to pay the applicable VA copayment as required by law.
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| 280 | Signature
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| 281 | SECTION IV - FIXED ASSETS (VETERAN AND SPOUSE)
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| 282 | 1. Residence (Market value minus any outstanding mortgage or
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| 283 | lien - exclude if veteran
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| 284 | receiving only non-institutional services or spouse or
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| 285 | dependent residing in community).
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| 286 | 2. Other Residences/Land/Farm or Ranch (Market value minus any
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| 287 | outstanding mortgage or lien)
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| 288 | 3. Vehicle(s)* (Value minus any outstanding lien - exclude if veteran is
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| 289 | receiving only
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| 290 | non-institutional services or spouse or dependent residing in community).
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| 291 | | SUBTOTAL (Sum of lines 1 through 3)
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| 292 | SECTION V - LIQUID ASSETS (VETERAN AND SPOUSE)
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| 293 | 1. Cash, e.g., interest, dividends from IRA, 401K's and other
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| 294 | tax deferred annuities
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| 295 | (including checking, savings, money market, etc.)
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| 296 | 2. Stocks, bonds, mutual funds, SEP's, and other retirement
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| 297 | annuities, self-employed person)
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| 298 | 3. Other Liquid Assets (Includes such items as stamp or coin
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| 299 | collections, art work, collectibles
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| 300 | household furniture and other household goods, clothing, jewelry, and
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| 301 | personal items
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| 302 | minus amount owed).
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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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