source: internationalization/trunk/TranslationSpreadsheets/WV-DIALOG-0064.txt@ 604

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

Internationalization

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1English French Notes Complete/Exclude
2subtracted is greater than the veteran's copayment then the assets
3will not be reduced.
4Do you wish to edit the LTC copay test
5 * VETERAN MAY BE EXEMPT FROM COPAY IF LTC EPISODE IS DUE TO THIS CONDITION.
6 Service Branch
7 Gulf War
8 Env Contam:
9 Mil Disab:
10 Dent Inj:
11 Purple Heart:
12 and Spouse
13Residence
14Other Residences/Land/Farm/or Ranch
15Vehicle(s)
16Cash, Stocks, Mutual Funds
17Other Liquid Assets
18Cash
19Stocks, Bonds, Mutual Funds, SEP's
20Current Employment Income
21Income from Farm/Ranch/Business
22Current Income
23Soc. Sec. Retire/Disabil
24Interest/Dividends
25Retirement/Pension Income
26Spouse VA Disabil/Compens
27Unemployment Benefit/Comp
28Other Compensation
29Court Mandated
30Other Income
31Education
32Funeral and Burial
33Rent/Mortgage
34Utilities
35Car Payment Only
36Food
37Non-reimbursed Medical Expenses
38Court-ordered Payments
39Taxes
40LTC copay test cannot be completed.
41...The LTC copay test has been completed with a status of
42Do you wish to complete the LTC copay test
43Does veteran decline to give income information
44Answer 'Y' or 'N'.
45Enter whether the veteran declines to provide current income information.
46An active spouse exists for this LTC copay test. Married should be 'YES'.
47LTC Copay Test Status
48A reason for exemption must be entered for an Exempt status.
49Does the veteran agree to pay copayments
50Enter in this field whether the veteran agrees to pay the
51LTC copayments. The veteran must also sign the 1010-EC form
52agreeing to pay the copayments. If the veteran does not agree
53to pay the copayments, the veteran becomes ineligible to
54receive extended care services.
55PRINT 10-10EC
56Veteran is EXEMPT from Long Term Care copayments.
57Reason for Exemption:
58ERROR: COULD NOT UPDATE LTC COPAY TEST
59LTC COPAY TEST FOR
60LTC Copayment Status:
61 Last Test:
62 **NEW TEST REQUIRED**
63Patient INELIGIBLE to Receive LTC Services -- Did Not Agree to Pay Copayments
64Reason:
65Assets:
66Agrees to Pay Copayments:
67NO *INELIGIBLE*
68Comment(s):
69** DETAILED LTC COPAY TEST INCOME INFORMATION IS NOT
70REQUIRED **
71AVAILABLE **
72** LTC COPAY TEST IS NO LONGER REQUIRED, INCOME INFORMATION MAY NOT BE ACCURATE **
73DETAILED LTC COPAY TEST INCOME INFORMATION COULD NOT BE CONVERTED FOR THE
74FOLLOWING RELATIONS ASSOCIATED WITH THIS LTC COPAY TEST:
75THE LTC COPAY TEST WOULD HAVE TO BE EDITED.
76TYPE OF BENEFIT-ENROLLMENT
77APPLICANT OTHER NAME
78CHILD(N)
79Sp.
80QUESTION
81VistA :
82APPLICANT SOCIAL SECURITY NUMBER
83EAS(
84APPLICANT DATE OF BIRTH
851010EZ data for
86 was not filed to
87 of File #
88A new record for
89 could not be created in
90 because Field #
91 produced an error:
92APPLICANT SEX
93MEDICARE PART A EFFECTIVE DATE
94PART A
95MEDICARE PART B EFFECTIVE DATE
96PART B
97MEDICARE CLAIM NUMBER
98SIGNEE ON MEDICARE CARD
99APPLICANT INSURANCE COMPANY
100APPLICANT INSURANCE GROUP CODE
101APPLICANT INSURANCE POLICY HOLDER
102APPLICANT INSURANCE POLICY NUMBER
103SPOUSE INSURANCE COMPANY
104SPOUSE INSURANCE GROUP CODE
105SPOUSE INSURANCE POLICY HOLDER
106SPOUSE INSURANCE POLICY NUMBER
107New Patient record added by ELECTRONIC 10-10EZ.
108Applicant Data
109Application #:
110Received:
111Veteran Type:
112Enter Applicant data as prompted --
113NEW PT. FROM ELECTRONIC 10-10EZ -- IN PROCESS
114Sorry... cannot link to selected Patient.
115Application #
116 is already linked to this Patient,
117and is still in-process.
118One moment please...
119Preparing for data comparison to VistA Patient database...
120EAS EZ 1010EZ INITIAL SCREEN
121Another user is processing that Application... try later.
122EAS EZ 1010EZ REVIEW1
123EAS EZ 1010EZ REVIEW2
124EAS EZ 1010EZ REVIEW3
125EAS EZ 1010EZ REVIEW4
126EAS EZ 1010EZ REVIEW5
127EAS EZ 1010EZ REVIEW6
128IN REVIEW
129PRINTED,PENDING SIG.
130Still filing...
131Application #:
132Applicant:
133Date Rec'd:
134Web ID #:
135Vet Sending Signed Form?:
136DATA ITEM
137Appointment Requested:
138Services Requested:
139Comments:
140Only two actions require a list line number indentifier --
141AF Accept Field
142AF=n
143 to act on the field shown in line #n.
144UF Update Field
145UF=n
146All other actions act on the Application as a whole,
147so a line number is not used.
148Actions
149Verify Signature
150File 10-10EZ
151Inactivate
152can be used only once per Application.
153Allowed actions for NEW Applications are:
154Allowed actions for IN REVIEW Applications are:
155Allowed actions for PENDING SIGNATURE Applications are:
156Allowed actions for SIGNED Applications are:
157Allowed actions for FILED Applications are:
158There are no allowed actions for an INACTIVATED Application.
159LZ Link to Patient File
160The veteran associated with a NEW Application must be 'linked' to
161the VistA Patient database.
162VistA Patient Lookup function is employed to match the applicant
163to an existing Patient OR to establish a new Patient record.
164AF Accept Field
165The 10-10 EZ data element on line #n is 'accepted' for later filing
166into the VistA Patient database.
167Using this action on a previously 'accepted' data element,
168removes the 'accepted' indicator.
169AZ Accept All
170All 10-10 EZ data element are 'accepted' for later filing into
171CZ Clear All
172The 'accepted' indicator is removed from any fields previously
173RZ Reset to New
174The Application is returned to the 'New' processing status.
175It can be re-matched to the VistA database.
176IZ Inactivate
177Once the Application is inactivated, it will no longer be available
178for processing.
179Use this action only if the Application is deemed invalid or is being
180replaced by a new Application.
181PZ Print 10-10EZ
182Once the 10-10EZ is Printed, actions of Accept Field, Accept All,
183Clear All, and Update Field can no longer be used.
184The 10-10EZ form is printed using all 'accepted' data.
185VistA Patient data is used for any fields not 'accepted'.
186Printing must be queued to a valid print device.
187VZ Verify Signature
188The user verifies that the Applicant's signature appears on a
189UF Update Field
190The 10-10 EZ data element on line #n can be overwritten by the user for
191later filing into VistA.
192This action should be used to enter the Applicant's hand-written
193changes to the signed 10-10EZ.
194FZ File 10-10EZ
195All 'accepted' data elements on the 10-10EZ are filed to the
196VistA Patient database.
197Use this action with caution -- 10-10EZ data elements will overwrite
198any existing data in Vista.
19910-10EZ Application Processing --
200Select Applications to View
201PRINTED, PENDING SIG.
202Application Status:
203Please wait while processing...
204Vet
205Applications not yet filed to the Patient database.
206Select an Application to view.
207No Applications meet the selection criteria.
208Application being processed by another user.
209Try again late.....
210VALM STACK
211 not allowed for this
212Do not select a slave device for output.
213This output requires a 132 column output printer.
2141010EZ PRINT
215The applicant has not been linked to the PATIENT File, #2
216This application has not been reviewed
217This application has already been closed, thE VA10-10EZ cannot be printed
218The VA10-10EZ for
219WEB submission ID:
220could not be printed for the following reason(s):
221OMB APPROVED NO. 2900-0091 / Est. Burden Avg. 20 min.
222APPLICATION FOR HEALTH BENEFITS
223APPLICATION FOR HEALTH BENEFITS, Continued
224AUTOMATED VA FORM 10-10EZ APR 1998
2251A. Type of Benefits Applied For:
2261B. If Applying For Health Services, Which VA Medical Center or Outpatient Clinic Do You Prefer
227|3. Other Names Used
2285. Social Security Number
229|6. Claim Number
230|7. Date of Birth
2319A. Current Mailing Address
232|10. Home Telephone Number
233|11. Work Telephone Number
23412. Current Marital Status:
23513A. Last Branch of Service
236|13B. Last Entry Date
237|13C.Last Discharge Date
238|13D. Discharge Type
239|13E. Military Service Number
24014. Answer Yes or No for the Following Questions
241Are You a Purple Heart Award Recipient
242Are You a Former Prisoner of War
243Do You Have a Military Dental Injury
244Do You Have a VA Service Connected Rating
245Do You Have a Spinal Cord Injury
246If Yes, What is Your Rated Percentage
247Are You Eligible for MEDICAID
248Are You Receiving a VA Pension:
249Are You Enrolled in MEDICARE Hospital Insurance Part A
250Are You Retired From The Military:
251Was Your Retirement The Result Of a Disability:
252Were You Regularly Retired (20+yrs.)
253Were You Exposed To Toxins In The Gulf War
254MEDICARE Claim Number
255Were You Exposed To Agent Orange
256Name Exactly As It Appears On Your MEDICARE Card
257Were You Exposed to Radiation
25815A. Veteran's Employment Status
259| 15B. Company Name, Address, Telephone
260Date of Retirement:
261(If employed or retired, complete 15B)
26216A. Spouse's Employment Status
263| 16B. Company Name, Address, Telephone
264(If employed or retired, complete 16B)
26517. Does The Veteran Have Health Insurance
266|18. Does The Spouse Have Health Insurance
267 (Other Than Medicare)
268| (Other Than Medicare)
26917A. Veteran's Health Insurance Co.
270|18A. Spouse's Health Insurance Co.
27117B. Name of Policy Holder
272|18B. Name of Policy Holder
27317C. Policy Number
274|17D. Group Code
275|18C. Policy Number
276|18D. Group Code
27719A. Name, Address and Relationship Of Next of Kin
278|19B. Home Telephone
279|19C. Work Telephone
28020A. Name, Adress and Relationship Of Emergency Contact
281|20B. Home Telephone
282|20C. Work Telephone
28321. I DESIGNATE THE FOLLOWING INDIVIDUAL TO RECEIVE POSSESSION OF ALL MY PERSONAL PROPERTY LEFT ON PREMISES UNDER VA CONTROL AFTER
284 MY DEPARTURE OR AT THE TIME OF MY DEATH. (This does not constitute a will or transfer of title.)
28522A. Is Need For Care Due To On The Job Injury
286|22B. Is Need For Care Due To Accident
287SECTION II - FINANCIAL ASSESSMENT
288IIA - DEPENDENT INFORMATION
2893. Spouse's Social Security Number
290|4. Spouse's Date Of Birth
291|5. Child's Date Of Birth
292|7. Child's Social Security Number
2938. Spouse's Telephone Number
294|9. Child's Relationship To You
29510. Date of Marriage
296|11. Date Child Became Your Dependent
29712. If Your Spouse or Dependent Child Did Not Live With You Last
298|13. Expenses Paid By YOUR Dependent Child for College, Vocational
299Year, Enter the Amount you Contributed To Their Support
300|Rehabilitation or Training (tuition, books, materials, etc.)
301Spouse $
302Child $
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