English French Notes Complete/Exclude subtracted is greater than the veteran's copayment then the assets will not be reduced. Do you wish to edit the LTC copay test * VETERAN MAY BE EXEMPT FROM COPAY IF LTC EPISODE IS DUE TO THIS CONDITION. Service Branch Gulf War Env Contam: Mil Disab: Dent Inj: Purple Heart: and Spouse Residence Other Residences/Land/Farm/or Ranch Vehicle(s) Cash, Stocks, Mutual Funds Other Liquid Assets Cash Stocks, Bonds, Mutual Funds, SEP's Current Employment Income Income from Farm/Ranch/Business Current Income Soc. Sec. Retire/Disabil Interest/Dividends Retirement/Pension Income Spouse VA Disabil/Compens Unemployment Benefit/Comp Other Compensation Court Mandated Other Income Education Funeral and Burial Rent/Mortgage Utilities Car Payment Only Food Non-reimbursed Medical Expenses Court-ordered Payments Taxes LTC copay test cannot be completed. ...The LTC copay test has been completed with a status of Do you wish to complete the LTC copay test Does veteran decline to give income information Answer 'Y' or 'N'. Enter whether the veteran declines to provide current income information. An active spouse exists for this LTC copay test. Married should be 'YES'. LTC Copay Test Status A reason for exemption must be entered for an Exempt status. Does the veteran agree to pay copayments Enter in this field whether the veteran agrees to pay the LTC copayments. The veteran must also sign the 1010-EC form agreeing to pay the copayments. If the veteran does not agree to pay the copayments, the veteran becomes ineligible to receive extended care services. PRINT 10-10EC Veteran is EXEMPT from Long Term Care copayments. Reason for Exemption: ERROR: COULD NOT UPDATE LTC COPAY TEST LTC COPAY TEST FOR LTC Copayment Status: Last Test: **NEW TEST REQUIRED** Patient INELIGIBLE to Receive LTC Services -- Did Not Agree to Pay Copayments Reason: Assets: Agrees to Pay Copayments: NO *INELIGIBLE* Comment(s): ** DETAILED LTC COPAY TEST INCOME INFORMATION IS NOT REQUIRED ** AVAILABLE ** ** LTC COPAY TEST IS NO LONGER REQUIRED, INCOME INFORMATION MAY NOT BE ACCURATE ** DETAILED LTC COPAY TEST INCOME INFORMATION COULD NOT BE CONVERTED FOR THE FOLLOWING RELATIONS ASSOCIATED WITH THIS LTC COPAY TEST: THE LTC COPAY TEST WOULD HAVE TO BE EDITED. TYPE OF BENEFIT-ENROLLMENT APPLICANT OTHER NAME CHILD(N) Sp. QUESTION VistA : APPLICANT SOCIAL SECURITY NUMBER EAS( APPLICANT DATE OF BIRTH 1010EZ data for was not filed to of File # A new record for could not be created in because Field # produced an error: APPLICANT SEX MEDICARE PART A EFFECTIVE DATE PART A MEDICARE PART B EFFECTIVE DATE PART B MEDICARE CLAIM NUMBER SIGNEE ON MEDICARE CARD APPLICANT INSURANCE COMPANY APPLICANT INSURANCE GROUP CODE APPLICANT INSURANCE POLICY HOLDER APPLICANT INSURANCE POLICY NUMBER SPOUSE INSURANCE COMPANY SPOUSE INSURANCE GROUP CODE SPOUSE INSURANCE POLICY HOLDER SPOUSE INSURANCE POLICY NUMBER New Patient record added by ELECTRONIC 10-10EZ. Applicant Data Application #: Received: Veteran Type: Enter Applicant data as prompted -- NEW PT. FROM ELECTRONIC 10-10EZ -- IN PROCESS Sorry... cannot link to selected Patient. Application # is already linked to this Patient, and is still in-process. One moment please... Preparing for data comparison to VistA Patient database... EAS EZ 1010EZ INITIAL SCREEN Another user is processing that Application... try later. EAS EZ 1010EZ REVIEW1 EAS EZ 1010EZ REVIEW2 EAS EZ 1010EZ REVIEW3 EAS EZ 1010EZ REVIEW4 EAS EZ 1010EZ REVIEW5 EAS EZ 1010EZ REVIEW6 IN REVIEW PRINTED,PENDING SIG. Still filing... Application #: Applicant: Date Rec'd: Web ID #: Vet Sending Signed Form?: DATA ITEM Appointment Requested: Services Requested: Comments: Only two actions require a list line number indentifier -- AF Accept Field AF=n to act on the field shown in line #n. UF Update Field UF=n All other actions act on the Application as a whole, so a line number is not used. Actions Verify Signature File 10-10EZ Inactivate can be used only once per Application. Allowed actions for NEW Applications are: Allowed actions for IN REVIEW Applications are: Allowed actions for PENDING SIGNATURE Applications are: Allowed actions for SIGNED Applications are: Allowed actions for FILED Applications are: There are no allowed actions for an INACTIVATED Application. LZ Link to Patient File The veteran associated with a NEW Application must be 'linked' to the VistA Patient database. VistA Patient Lookup function is employed to match the applicant to an existing Patient OR to establish a new Patient record. AF Accept Field The 10-10 EZ data element on line #n is 'accepted' for later filing into the VistA Patient database. Using this action on a previously 'accepted' data element, removes the 'accepted' indicator. AZ Accept All All 10-10 EZ data element are 'accepted' for later filing into CZ Clear All The 'accepted' indicator is removed from any fields previously RZ Reset to New The Application is returned to the 'New' processing status. It can be re-matched to the VistA database. IZ Inactivate Once the Application is inactivated, it will no longer be available for processing. Use this action only if the Application is deemed invalid or is being replaced by a new Application. PZ Print 10-10EZ Once the 10-10EZ is Printed, actions of Accept Field, Accept All, Clear All, and Update Field can no longer be used. The 10-10EZ form is printed using all 'accepted' data. VistA Patient data is used for any fields not 'accepted'. Printing must be queued to a valid print device. VZ Verify Signature The user verifies that the Applicant's signature appears on a UF Update Field The 10-10 EZ data element on line #n can be overwritten by the user for later filing into VistA. This action should be used to enter the Applicant's hand-written changes to the signed 10-10EZ. FZ File 10-10EZ All 'accepted' data elements on the 10-10EZ are filed to the VistA Patient database. Use this action with caution -- 10-10EZ data elements will overwrite any existing data in Vista. 10-10EZ Application Processing -- Select Applications to View PRINTED, PENDING SIG. Application Status: Please wait while processing... Vet Applications not yet filed to the Patient database. Select an Application to view. No Applications meet the selection criteria. Application being processed by another user. Try again late..... VALM STACK not allowed for this Do not select a slave device for output. This output requires a 132 column output printer. 1010EZ PRINT The applicant has not been linked to the PATIENT File, #2 This application has not been reviewed This application has already been closed, thE VA10-10EZ cannot be printed The VA10-10EZ for WEB submission ID: could not be printed for the following reason(s): OMB APPROVED NO. 2900-0091 / Est. Burden Avg. 20 min. APPLICATION FOR HEALTH BENEFITS APPLICATION FOR HEALTH BENEFITS, Continued AUTOMATED VA FORM 10-10EZ APR 1998 1A. Type of Benefits Applied For: 1B. If Applying For Health Services, Which VA Medical Center or Outpatient Clinic Do You Prefer |3. Other Names Used 5. Social Security Number |6. Claim Number |7. Date of Birth 9A. Current Mailing Address |10. Home Telephone Number |11. Work Telephone Number 12. Current Marital Status: 13A. Last Branch of Service |13B. Last Entry Date |13C.Last Discharge Date |13D. Discharge Type |13E. Military Service Number 14. Answer Yes or No for the Following Questions Are You a Purple Heart Award Recipient Are You a Former Prisoner of War Do You Have a Military Dental Injury Do You Have a VA Service Connected Rating Do You Have a Spinal Cord Injury If Yes, What is Your Rated Percentage Are You Eligible for MEDICAID Are You Receiving a VA Pension: Are You Enrolled in MEDICARE Hospital Insurance Part A Are You Retired From The Military: Was Your Retirement The Result Of a Disability: Were You Regularly Retired (20+yrs.) Were You Exposed To Toxins In The Gulf War MEDICARE Claim Number Were You Exposed To Agent Orange Name Exactly As It Appears On Your MEDICARE Card Were You Exposed to Radiation 15A. Veteran's Employment Status | 15B. Company Name, Address, Telephone Date of Retirement: (If employed or retired, complete 15B) 16A. Spouse's Employment Status | 16B. Company Name, Address, Telephone (If employed or retired, complete 16B) 17. Does The Veteran Have Health Insurance |18. Does The Spouse Have Health Insurance (Other Than Medicare) | (Other Than Medicare) 17A. Veteran's Health Insurance Co. |18A. Spouse's Health Insurance Co. 17B. Name of Policy Holder |18B. Name of Policy Holder 17C. Policy Number |17D. Group Code |18C. Policy Number |18D. Group Code 19A. Name, Address and Relationship Of Next of Kin |19B. Home Telephone |19C. Work Telephone 20A. Name, Adress and Relationship Of Emergency Contact |20B. Home Telephone |20C. Work Telephone 21. I DESIGNATE THE FOLLOWING INDIVIDUAL TO RECEIVE POSSESSION OF ALL MY PERSONAL PROPERTY LEFT ON PREMISES UNDER VA CONTROL AFTER MY DEPARTURE OR AT THE TIME OF MY DEATH. (This does not constitute a will or transfer of title.) 22A. Is Need For Care Due To On The Job Injury |22B. Is Need For Care Due To Accident SECTION II - FINANCIAL ASSESSMENT IIA - DEPENDENT INFORMATION 3. Spouse's Social Security Number |4. Spouse's Date Of Birth |5. Child's Date Of Birth |7. Child's Social Security Number 8. Spouse's Telephone Number |9. Child's Relationship To You 10. Date of Marriage |11. Date Child Became Your Dependent 12. If Your Spouse or Dependent Child Did Not Live With You Last |13. Expenses Paid By YOUR Dependent Child for College, Vocational Year, Enter the Amount you Contributed To Their Support |Rehabilitation or Training (tuition, books, materials, etc.) Spouse $ Child $ #################### #################### #################### #################### #################### #################### #################### #################### #################### #################### #################### #################### #################### #################### ####################