source: internationalization/trunk/TranslationSpreadsheets/WV-DIALOG-0063.txt@ 1154

Last change on this file since 1154 was 604, checked in by George Lilly, 15 years ago

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1English French Notes Complete/Exclude
2SUM OF ALL LINES FIXED AND LIQUID ASSETS
3TOTAL ASSETS
4Current income, e.g. gross income (including, but not limited
5to, wages and income from
6a business, bonuses, tips, severance pay, accrued benefits,
7cash gifts)
8Social Security Retirement/Disability
9Interest/Dividends (i.e., interest income, standard dividend
10income from non tax deferred
11Retirement and Pension income
12Civil Service Retirement
13US Railroad Retirement
14VA Pension
15Spouse VA disability/compensation
16Unemployment Benefits/Compensation
17Other compensation, e.g. Workers Compensation and Black Lung
18Court Mandated (e.g. alimony, child support) (Veteran and Spouse)
19Other Income (i.e., inheritance amounts, tort settlement
20SECTION VI - EXPENSES
211. Education (veteran, spouse or dependent)
222. Funeral and Burial (spouse or child)
235. Car Payment Only (excludes gas, insurance, parking fees)
247. Non-reimbursed medical expenses
258. Court-ordered payments
269. Insurance (exclude life insurance)
2710. Taxes (on any amount include in gross income, property, personal)
28SECTION
29 - CONSENT FOR ASSIGNMENT OF BENEFITS
30I hereby authorize the Department of Veterans Affairs to disclose any such history, diagnostic and treatment information from my
31medical records to the contractor of any health plan contract under which I am apparently eligible for medical care or payment of
32the expense of care or to any other party against whom liability is asserted. I understand that I may revoke this authorization at
33any time, except to the extent that action has already been taken in reliance on it. Without my express revocation, this consent
34will automatically expire when all action arising from VA's claim for reimbursement from my medical care has been completed.
35I authorize payment of medical benefits to VA for any services for which payment is accepted.
36 - CONSENT AND AGREEMENT TO MAKE COPAYMENTS
37has received a copy of the Privacy Act Statement and agrees to make appropriate copayments.
38I certify the foregoing statement(s) are true and correct to the best of my knowledge and belief and agree to make the applicable
39copayment for extended care services as required by law.
40Additional Comments:
41This output requires a 132 column printer.
421010EC PRINT
43APPLICATION FOR EXTENDED CARE SERVICES
44SECTION I - GENERAL INFORMATION
45APPLICATION FOR EXTENDED CARE SERVICES, Continued
46| Social Security Number
47VA FORM 10-10EC DEC
481. Primary Residence (Market value minus mortgages or liens.
49Exclude if veteran receiving only
50non-institutional extended care services or spouse or dependent residing in community. If the
51veteran and spouse maintain separate residences, and the veteran is receiving institutional
52(inpatient) extended care services, include value of the veteran's primary residence.)
53This would
54include a second home, vacation home, rental property.)
553. Vehicle(s) (Value minus outstanding lien. Exclude primary vehicle if veteran
56institutional (inpatient) extended care services, include value of veteran's primary vehicle.)
571. Cash, Amount in Bank Accounts (e.g., checking and savings accounts, certificates
58of deposit
59individual retirement accounts, stocks and bonds.)
602. Value of Other Liquid Assets (e.g., art, rare coins, stamp collections, collectibles) Minus
61the amount you owe on these items. Exclude household effects, clothing, jewelry, and personal
62items if veteran receiving only non-institutional extended care services or spouse or
63dependent residing in the community.
64 SUM OF ALL LINES FIXED AND LIQUID ASSETS
65| TOTAL ASSETS
66SECTION VI - CURRENT GROSS INCOME OF VETERAN AND SPOUSE
671. Gross annual income from employment (e.g., wages, bonuses, tips, severance pay
68accrued benefits)
692. Net income from your farm/ranch, property or business.
703. List other income amounts (e.g., Social Security, retirement and pension,
71interest, dividends) Refer to instructions.
72SECTION VII - DEDUCTIBLE EXPENSES
731. Educational expenses of veteran, spouse or dependent (e.g., tuition, books, fees, material, etc.)
742. Funeral and Burial (spouse or child, amount you paid for funeral and burial expenses, including prepaid
753. Rent/Mortgage (monthly amount or annual amount)
764. Utilities (calculate by average monthly amounts over the past 12 months)
775. Car Payment for one vehicle only (exclude gas, automobile insurance, parking fees, repairs)
786. Food (for veteran, spouse and dependent)
797. Non-reimbursed medical expenses paid by you or spouse (e.g., copayments for physicians, dentists,
80medications, Medicare, health insurance, hospital and nursing home expenses)
818. Court-ordered payments (e.g., alimony, child support)
829. Insurance (e.g., automobile insurance, homeowners insurance) Exclude life insurance
8310. Taxes (e.g., personal property for home, automobile) Include average monthly expense for taxes paid on
84income over the past 12 months.
85SECTION X - PAPERWORK PRIVACY ACT INFORMATION
86The Paperwork Reduction Act of 1995 requires us to notify you that this information collection is in accordance with the clearance
87requirements of section 3507 of the Paperwork Reduction Act of 1995. We may not conduct or sponsor, and you are not required to
88respond to, a collection of information unless it displays a valid OMB number. We anticipate that the time expended by all
89individuals who must complete this form will average 90 minutes. This includes the time it will take to read instructions, gather
90the necessary facts and fill out the form. If you have comments regarding this burden estimate or any other aspect of this
91collection, call 202.273.8247 for mailing information on where to send your comments.
92Privacy Act Information: The VA is asking you to provide the information on this form under Title 38, United States Code,
93sections 1710, 1712, 1722 and 1729 in order for VA to determine your eligibility for extended care benefits and to establish
94financial eligibility, if applicable, when placed in extended care services. The information you supply may be verified through a
95computer-matching program. VA may disclose the information that you put on the form as permitted by law. VA may make a
96routine use
97 disclosure of the information as outlined in the Privacy Act systems of records notices and in accordance with the
98VHA Notice of Privacy Practices. You do not have to provide the information to VA, but if you don't, VA will be unable to process
99your request and serve your medical needs. Failure to furnish the information will not have any affect on any other benefits to
100which you may be entitled. If you provide VA your Social Security Number, VA will use it to administer your VA benefits. VA may
101also use this information to identify veterans and persons claiming or receiving VA benefits and their records, and for other
102purposes authorized or required by law.
103Patient is not a Veteran.
104Date of LTC Copay Test:
105The date of test must be after the date of the last test on
106An LTC Copay Test already exists on
107Are you sure you want to add a new test
108LTC COPAY
109 Use the 'EASEC
110TEST EDIT' Option.
111TEST VIEW' Option.
112Is veteran EXEMPT from LTC copayments
113Enter either 'Y' or 'N'.
114Answer 'Yes' if the veteran is exempt from LTC copayments
115for a reason other than low income.
116Reason for Exemption
117A reason for exemption must be entered. LTC Copay Test cannot be added.
118Veteran is NOT EXEMPT from Long Term Care copayments based
119on last year's income and must complete a 10-10EC form.
120Enter in this field the annual amount of Social Security
121received during the current calendar year.
122A monthly amount can be entered with an '*' after it.
123Enter in this field the annual amount of U.S. Civil Service
124Enter in this field the annual amount of Military Retirement
125Enter in this field the annual amount of Other Retirement received
126during the current calendar year. This includes company, state,
127Enter in this field the annual amount of Gross Income received during
128the current year. This includes, but is not limited to, wages and
129income from a business, bonuses, tips, severance pay, accrued
130benefits, cash gifts.
131Enter in this field the annual amount of Net Income received during
132the current calendar year from the operation of a farm, ranch,
133property or business.
134Enter in this field the annual amount of Interest and Dividend
135Income received during the current calendar year (i.e., interest
136income, standard dividend income from non tax deferred annuities).
137Enter in this field the annual amount of Workers Compensation or
138Black Lung Benefits received during the current calendar year.
139Enter in this field the annual amount of All Other Income received
140during the current calendar year, including retirement and pension
141income, Social Security Retirement and Social Security Disability
142income, compensation benefits such as unemployment, Workers and
143Black Lung, or VA disability. Also cash gifts, court mandated
144payments, inheritance amounts, tort settlement payments, interest
145and dividends, including tax exempt earnings and distributions from
146Individual Retirement Accounts (IRAs) or annuities.
147received during the current calendar year (i.e., inheritance amounts,
148tort settlement payments).
149Enter in this field the total amount of unreimbursed medical expenses
150paid by the veteran during the current calendar year. The expenses
151can be for the veteran or for members of the veteran's family.
152Reportable medical expenses include amounts paid for the following:
153fees of physicians, dentists, and other providers of health services;
154hospital and nursing home fees; medical insurance premiums (including
155the Medicare premium); drugs and medicines; eyeglasses; any other
156expenses that are reasonable related to medical care. The expenses
157must actually have been paid by the veteran. Do not list expenses
158which have not been paid or which have been paid by someone other
159than the veteran. Do not list expenses which the veteran has paid if
160the veteran expects to receive reimbursement from insurance or some
161other source.
162calendar year for funeral or burial expenses of the veteran's
163spouse or child, or pre-paid arrangements for the veteran.
164Do not report amounts paid for funeral or burial expenses of other
165relatives such as parents, siblings, etc.
166Enter in this field the total amount paid by the veteran for
167educational expenses during the current calendar year. This
168includes educational expenses for the veteran, spouse and children.
169Educational expenses are tuition, fees, and books if enrolled in a
170program of education.
171Enter in this field cash and amounts in bank accounts. This
172includes checking accounts, savings accounts, money markets,
173interest, dividends from IRA, 401K's, and other tax deferred
174Enter in this field the current value of stocks, bonds, mutual
175funds, SEP's, and other retirement accounts (e.g., IRA, 401K,
176annuities, self-employed person).
177 has no LTC copay (10-10EC) tests on file.
178This LTC Copay Test (10-10EC) is uneditable and cannot be deleted.
179Display test
180 <OK, nothing deleted!>
181 <LTC Copay Test deleted.>
182Pat ID:
183 LTC Copay Test Date Status:
184Source:
185EASEC DEPENDENTS
186Cannot edit when viewing a LTC copay test.
187Not a LTC copay test - use LTC copay test options.
188 as a dependent to the LTC copay test.
189Not applicable for LTC copay test
190Married This Year:
191Legally Separated:
192Spouse Residing in Community:
193Living with Spouse:
194Dependent Residing in Community:
195Dependent Living with You:
196EASEC EXPAND PROFILE
197Select DATE OF LTC COPAY TEST:
198Warning: Uneditable LTC Copay test. The source of this test is
199Would you like to view the LTC Copay test or print the 10-10EC
200Enter a date that is less than or equal to today.
201Enter the date of the LTC Copay Test.
202Are you sure you want to change the date of the LTC Copay Test
203must complete a 10-10EC form.
204Report of LTC Copayment Tests
205Enter 1 or 2
206Indicate whether the report should include:
207(1) a list of veterans whose LTC Copayment Test is pending expiration (i.e.,
208the anniversary date of the test is approaching) within a user-specified
209number of days, or
210(2) a list of veterans whose LTC Copayment Test has already expired (i.e.,
211the anniversary date of the test has passed) since a user-specified date.
212Enter number of days to report
213Enter a start date
214Sort report by Name or Date
215Indicate whether the report should be sorted by the
216Veteran's Name or the LTC Copay Test Anniversary Date
217Report Cancelled!
218LTC COPAY TESTS
219Report
220Queued!
221Cancelled!
222*** No records to print ***
223VETERANS WITH LONG TERM CARE COPAYMENT TESTS THAT
224ARE PENDING EXPIRATION IN
225HAVE EXPIRED SINCE
226SORTED BY
227REPORT DATE:
228LTC Test
229Veteran's Name
230Anniversary Date
231The income threshold check could not be completed due to an error.
232Means Test
233LTC Copay Exemption Test
234The previous year's financial information is not on file for this veteran.
235 is required.
236 at this time
237Report of Calculated Long Term Care Copayments
238No LTC Copayment Test on file for this veteran!
239Copayment rates for LTC are not available at this time.
240The LTC Copayment Test is incomplete!
241This veteran is Exempt from LTC copayments!
242This LTC Copayment Test contains an invalid status!
243Enter the LTC Admission Date
244Enter the admission date for the current institutional
245Long Term Care episode.
246Enter the Report Start Date (Month/Year)
247Enter the starting date for the report in the format month/year (e.g. 9/03).
248The report will print 12 months of copayments starting with the
249month and year entered.
250Report Start Date cannot be before LTC Admission Date!
251LTC Copay Calculation Report
252SPOUSE RESIDING IN THE COMMUNITY
253*** DECLINED TO PROVIDE INCOME INFORMATION -- AGREED TO PAY COPAYMENTS ***
254*** VETERAN IS INELIGIBLE FOR LTC SERVICES -- REFUSED TO SIGN 10-10EC ***
255LTC COPAY TEST DATE:
256LTC ADMISSION DATE:
257LTC COPAYMENT CALCULATION
258FOR DAYS 1-180
259FOR DAYS 181+
260TOT ASSETS
261TOT INCOME
262TOT EXPENSES
263TOT ALLOWANCE
264CALC COPAY
265MAX COPAY
266VET COPAY
267LONG TERM CARE ESTIMATED COPAYMENTS FOR
268NON-
269INSTITUTIONAL SERVICES
270TOTAL INCOME - TOTAL EXPENSES - TOTAL ALLOWANCE
271(TOTAL ASSETS + TOTAL INCOME) - TOTAL EXPENSES - TOTAL ALLOWANCE
272(TOTAL ASSETS + TOTAL INCOME) - TOTAL ALLOWANCE
273IMPORTANT NOTICE: The copayment amounts shown in this report are
274based on calculations of the copayment amount for
275an entire month. The
276copayment amounts will be adjusted to
277reflect the actual start date of LTC
278services and the
279copayment exemption for the first 21 days of service. The VET
280COPAY amount is based on the assumption that the veteran
281will be responsible
282to pay the lesser of EITHER the calculated
283 copayment (CALC COPAY) OR the
284maximum copayment (MAX COPAY).
285In the event that the calculated copayment
286(CALC COPAY) is a
287negative figure, the veteran copayment (VET COPAY)
288will be adjusted to zero (0). If the veteran declined to provide
289information, the veteran will be obligated to pay the
290 maximum copayment.
291EXPLANATION OF ASSET SPEND DOWN CALCULATION:
292The veteran's assets are included in the calculation of copayments
293after 180 days of institutional LTC services. The assets then may
294be reduced each month according to the following formula:
295Single Veteran:
296 TOTAL ASSETS-(VET COPAY-(INCOME-ALLOWANCE))
297Married Veteran (spouse residing in the community):
298 TOTAL ASSETS-(VET COPAY-(INCOME-EXPENSES-ALLOWANCE))
299In other words, the assets will be reduced by the amount of the
300veteran's copayment that is not covered by the veteran's income
301after all expenses and allowances are subtracted. If the amount
302of the veteran's income after all expenses and allowances are
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