| 1 | English French Notes Complete/Exclude
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| 2 | subtracted is greater than the veteran's copayment then the assets
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| 3 | will not be reduced.
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| 4 | Do you wish to edit the LTC copay test
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| 5 | * VETERAN MAY BE EXEMPT FROM COPAY IF LTC EPISODE IS DUE TO THIS CONDITION.
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| 6 | Service Branch
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| 7 | Gulf War
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| 8 | Env Contam:
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| 9 | Mil Disab:
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| 10 | Dent Inj:
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| 11 | Purple Heart:
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| 12 | and Spouse
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| 13 | Residence
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| 14 | Other Residences/Land/Farm/or Ranch
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| 15 | Vehicle(s)
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| 16 | Cash, Stocks, Mutual Funds
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| 17 | Other Liquid Assets
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| 18 | Cash
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| 19 | Stocks, Bonds, Mutual Funds, SEP's
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| 20 | Current Employment Income
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| 21 | Income from Farm/Ranch/Business
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| 22 | Current Income
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| 23 | Soc. Sec. Retire/Disabil
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| 24 | Interest/Dividends
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| 25 | Retirement/Pension Income
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| 26 | Spouse VA Disabil/Compens
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| 27 | Unemployment Benefit/Comp
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| 28 | Other Compensation
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| 29 | Court Mandated
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| 30 | Other Income
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| 31 | Education
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| 32 | Funeral and Burial
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| 33 | Rent/Mortgage
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| 34 | Utilities
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| 35 | Car Payment Only
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| 36 | Food
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| 37 | Non-reimbursed Medical Expenses
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| 38 | Court-ordered Payments
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| 39 | Taxes
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| 40 | LTC copay test cannot be completed.
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| 41 | ...The LTC copay test has been completed with a status of
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| 42 | Do you wish to complete the LTC copay test
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| 43 | Does veteran decline to give income information
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| 44 | Answer 'Y' or 'N'.
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| 45 | Enter whether the veteran declines to provide current income information.
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| 46 | An active spouse exists for this LTC copay test. Married should be 'YES'.
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| 47 | LTC Copay Test Status
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| 48 | A reason for exemption must be entered for an Exempt status.
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| 49 | Does the veteran agree to pay copayments
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| 50 | Enter in this field whether the veteran agrees to pay the
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| 51 | LTC copayments. The veteran must also sign the 1010-EC form
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| 52 | agreeing to pay the copayments. If the veteran does not agree
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| 53 | to pay the copayments, the veteran becomes ineligible to
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| 54 | receive extended care services.
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| 55 | PRINT 10-10EC
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| 56 | Veteran is EXEMPT from Long Term Care copayments.
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| 57 | Reason for Exemption:
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| 58 | ERROR: COULD NOT UPDATE LTC COPAY TEST
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| 59 | LTC COPAY TEST FOR
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| 60 | LTC Copayment Status:
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| 61 | Last Test:
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| 62 | **NEW TEST REQUIRED**
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| 63 | Patient INELIGIBLE to Receive LTC Services -- Did Not Agree to Pay Copayments
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| 64 | Reason:
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| 65 | Assets:
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| 66 | Agrees to Pay Copayments:
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| 67 | NO *INELIGIBLE*
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| 68 | Comment(s):
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| 69 | ** DETAILED LTC COPAY TEST INCOME INFORMATION IS NOT
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| 70 | REQUIRED **
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| 71 | AVAILABLE **
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| 72 | ** LTC COPAY TEST IS NO LONGER REQUIRED, INCOME INFORMATION MAY NOT BE ACCURATE **
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| 73 | DETAILED LTC COPAY TEST INCOME INFORMATION COULD NOT BE CONVERTED FOR THE
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| 74 | FOLLOWING RELATIONS ASSOCIATED WITH THIS LTC COPAY TEST:
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| 75 | THE LTC COPAY TEST WOULD HAVE TO BE EDITED.
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| 76 | TYPE OF BENEFIT-ENROLLMENT
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| 77 | APPLICANT OTHER NAME
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| 78 | CHILD(N)
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| 79 | Sp.
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| 80 | QUESTION
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| 81 | VistA :
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| 82 | APPLICANT SOCIAL SECURITY NUMBER
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| 83 | EAS(
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| 84 | APPLICANT DATE OF BIRTH
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| 85 | 1010EZ data for
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| 86 | was not filed to
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| 87 | of File #
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| 88 | A new record for
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| 89 | could not be created in
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| 90 | because Field #
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| 91 | produced an error:
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| 92 | APPLICANT SEX
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| 93 | MEDICARE PART A EFFECTIVE DATE
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| 94 | PART A
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| 95 | MEDICARE PART B EFFECTIVE DATE
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| 96 | PART B
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| 97 | MEDICARE CLAIM NUMBER
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| 98 | SIGNEE ON MEDICARE CARD
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| 99 | APPLICANT INSURANCE COMPANY
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| 100 | APPLICANT INSURANCE GROUP CODE
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| 101 | APPLICANT INSURANCE POLICY HOLDER
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| 102 | APPLICANT INSURANCE POLICY NUMBER
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| 103 | SPOUSE INSURANCE COMPANY
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| 104 | SPOUSE INSURANCE GROUP CODE
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| 105 | SPOUSE INSURANCE POLICY HOLDER
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| 106 | SPOUSE INSURANCE POLICY NUMBER
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| 107 | New Patient record added by ELECTRONIC 10-10EZ.
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| 108 | Applicant Data
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| 109 | Application #:
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| 110 | Received:
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| 111 | Veteran Type:
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| 112 | Enter Applicant data as prompted --
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| 113 | NEW PT. FROM ELECTRONIC 10-10EZ -- IN PROCESS
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| 114 | Sorry... cannot link to selected Patient.
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| 115 | Application #
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| 116 | is already linked to this Patient,
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| 117 | and is still in-process.
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| 118 | One moment please...
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| 119 | Preparing for data comparison to VistA Patient database...
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| 120 | EAS EZ 1010EZ INITIAL SCREEN
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| 121 | Another user is processing that Application... try later.
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| 122 | EAS EZ 1010EZ REVIEW1
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| 123 | EAS EZ 1010EZ REVIEW2
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| 124 | EAS EZ 1010EZ REVIEW3
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| 125 | EAS EZ 1010EZ REVIEW4
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| 126 | EAS EZ 1010EZ REVIEW5
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| 127 | EAS EZ 1010EZ REVIEW6
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| 128 | IN REVIEW
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| 129 | PRINTED,PENDING SIG.
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| 130 | Still filing...
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| 131 | Application #:
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| 132 | Applicant:
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| 133 | Date Rec'd:
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| 134 | Web ID #:
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| 135 | Vet Sending Signed Form?:
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| 136 | DATA ITEM
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| 137 | Appointment Requested:
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| 138 | Services Requested:
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| 139 | Comments:
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| 140 | Only two actions require a list line number indentifier --
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| 141 | AF Accept Field
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| 142 | AF=n
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| 143 | to act on the field shown in line #n.
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| 144 | UF Update Field
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| 145 | UF=n
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| 146 | All other actions act on the Application as a whole,
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| 147 | so a line number is not used.
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| 148 | Actions
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| 149 | Verify Signature
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| 150 | File 10-10EZ
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| 151 | Inactivate
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| 152 | can be used only once per Application.
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| 153 | Allowed actions for NEW Applications are:
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| 154 | Allowed actions for IN REVIEW Applications are:
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| 155 | Allowed actions for PENDING SIGNATURE Applications are:
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| 156 | Allowed actions for SIGNED Applications are:
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| 157 | Allowed actions for FILED Applications are:
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| 158 | There are no allowed actions for an INACTIVATED Application.
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| 159 | LZ Link to Patient File
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| 160 | The veteran associated with a NEW Application must be 'linked' to
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| 161 | the VistA Patient database.
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| 162 | VistA Patient Lookup function is employed to match the applicant
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| 163 | to an existing Patient OR to establish a new Patient record.
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| 164 | AF Accept Field
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| 165 | The 10-10 EZ data element on line #n is 'accepted' for later filing
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| 166 | into the VistA Patient database.
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| 167 | Using this action on a previously 'accepted' data element,
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| 168 | removes the 'accepted' indicator.
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| 169 | AZ Accept All
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| 170 | All 10-10 EZ data element are 'accepted' for later filing into
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| 171 | CZ Clear All
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| 172 | The 'accepted' indicator is removed from any fields previously
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| 173 | RZ Reset to New
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| 174 | The Application is returned to the 'New' processing status.
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| 175 | It can be re-matched to the VistA database.
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| 176 | IZ Inactivate
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| 177 | Once the Application is inactivated, it will no longer be available
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| 178 | for processing.
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| 179 | Use this action only if the Application is deemed invalid or is being
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| 180 | replaced by a new Application.
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| 181 | PZ Print 10-10EZ
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| 182 | Once the 10-10EZ is Printed, actions of Accept Field, Accept All,
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| 183 | Clear All, and Update Field can no longer be used.
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| 184 | The 10-10EZ form is printed using all 'accepted' data.
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| 185 | VistA Patient data is used for any fields not 'accepted'.
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| 186 | Printing must be queued to a valid print device.
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| 187 | VZ Verify Signature
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| 188 | The user verifies that the Applicant's signature appears on a
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| 189 | UF Update Field
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| 190 | The 10-10 EZ data element on line #n can be overwritten by the user for
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| 191 | later filing into VistA.
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| 192 | This action should be used to enter the Applicant's hand-written
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| 193 | changes to the signed 10-10EZ.
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| 194 | FZ File 10-10EZ
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| 195 | All 'accepted' data elements on the 10-10EZ are filed to the
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| 196 | VistA Patient database.
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| 197 | Use this action with caution -- 10-10EZ data elements will overwrite
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| 198 | any existing data in Vista.
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| 199 | 10-10EZ Application Processing --
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| 200 | Select Applications to View
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| 201 | PRINTED, PENDING SIG.
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| 202 | Application Status:
|
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| 203 | Please wait while processing...
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| 204 | Vet
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| 205 | Applications not yet filed to the Patient database.
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| 206 | Select an Application to view.
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| 207 | No Applications meet the selection criteria.
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| 208 | Application being processed by another user.
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| 209 | Try again late.....
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| 210 | VALM STACK
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| 211 | not allowed for this
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| 212 | Do not select a slave device for output.
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| 213 | This output requires a 132 column output printer.
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| 214 | 1010EZ PRINT
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| 215 | The applicant has not been linked to the PATIENT File, #2
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| 216 | This application has not been reviewed
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| 217 | This application has already been closed, thE VA10-10EZ cannot be printed
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| 218 | The VA10-10EZ for
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| 219 | WEB submission ID:
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| 220 | could not be printed for the following reason(s):
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| 221 | OMB APPROVED NO. 2900-0091 / Est. Burden Avg. 20 min.
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| 222 | APPLICATION FOR HEALTH BENEFITS
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| 223 | APPLICATION FOR HEALTH BENEFITS, Continued
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| 224 | AUTOMATED VA FORM 10-10EZ APR 1998
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| 225 | 1A. Type of Benefits Applied For:
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| 226 | 1B. If Applying For Health Services, Which VA Medical Center or Outpatient Clinic Do You Prefer
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| 227 | |3. Other Names Used
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| 228 | 5. Social Security Number
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| 229 | |6. Claim Number
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| 230 | |7. Date of Birth
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| 231 | 9A. Current Mailing Address
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| 232 | |10. Home Telephone Number
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| 233 | |11. Work Telephone Number
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| 234 | 12. Current Marital Status:
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| 235 | 13A. Last Branch of Service
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| 236 | |13B. Last Entry Date
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| 237 | |13C.Last Discharge Date
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| 238 | |13D. Discharge Type
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| 239 | |13E. Military Service Number
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| 240 | 14. Answer Yes or No for the Following Questions
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| 241 | Are You a Purple Heart Award Recipient
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| 242 | Are You a Former Prisoner of War
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| 243 | Do You Have a Military Dental Injury
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|---|
| 244 | Do You Have a VA Service Connected Rating
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|---|
| 245 | Do You Have a Spinal Cord Injury
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| 246 | If Yes, What is Your Rated Percentage
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| 247 | Are You Eligible for MEDICAID
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| 248 | Are You Receiving a VA Pension:
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| 249 | Are You Enrolled in MEDICARE Hospital Insurance Part A
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| 250 | Are You Retired From The Military:
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| 251 | Was Your Retirement The Result Of a Disability:
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|---|
| 252 | Were You Regularly Retired (20+yrs.)
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| 253 | Were You Exposed To Toxins In The Gulf War
|
|---|
| 254 | MEDICARE Claim Number
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|---|
| 255 | Were You Exposed To Agent Orange
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|---|
| 256 | Name Exactly As It Appears On Your MEDICARE Card
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| 257 | Were You Exposed to Radiation
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| 258 | 15A. Veteran's Employment Status
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| 259 | | 15B. Company Name, Address, Telephone
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| 260 | Date of Retirement:
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| 261 | (If employed or retired, complete 15B)
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| 262 | 16A. Spouse's Employment Status
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|---|
| 263 | | 16B. Company Name, Address, Telephone
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| 264 | (If employed or retired, complete 16B)
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| 265 | 17. Does The Veteran Have Health Insurance
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| 266 | |18. Does The Spouse Have Health Insurance
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| 267 | (Other Than Medicare)
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| 268 | | (Other Than Medicare)
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| 269 | 17A. Veteran's Health Insurance Co.
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| 270 | |18A. Spouse's Health Insurance Co.
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| 271 | 17B. Name of Policy Holder
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| 272 | |18B. Name of Policy Holder
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|---|
| 273 | 17C. Policy Number
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|---|
| 274 | |17D. Group Code
|
|---|
| 275 | |18C. Policy Number
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|---|
| 276 | |18D. Group Code
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|---|
| 277 | 19A. Name, Address and Relationship Of Next of Kin
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| 278 | |19B. Home Telephone
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| 279 | |19C. Work Telephone
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|---|
| 280 | 20A. Name, Adress and Relationship Of Emergency Contact
|
|---|
| 281 | |20B. Home Telephone
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|---|
| 282 | |20C. Work Telephone
|
|---|
| 283 | 21. I DESIGNATE THE FOLLOWING INDIVIDUAL TO RECEIVE POSSESSION OF ALL MY PERSONAL PROPERTY LEFT ON PREMISES UNDER VA CONTROL AFTER
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| 284 | MY DEPARTURE OR AT THE TIME OF MY DEATH. (This does not constitute a will or transfer of title.)
|
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| 285 | 22A. Is Need For Care Due To On The Job Injury
|
|---|
| 286 | |22B. Is Need For Care Due To Accident
|
|---|
| 287 | SECTION II - FINANCIAL ASSESSMENT
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| 288 | IIA - DEPENDENT INFORMATION
|
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| 289 | 3. 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
|
|---|
| 293 | 8. Spouse's Telephone Number
|
|---|
| 294 | |9. Child's Relationship To You
|
|---|
| 295 | 10. Date of Marriage
|
|---|
| 296 | |11. Date Child Became Your Dependent
|
|---|
| 297 | 12. If Your Spouse or Dependent Child Did Not Live With You Last
|
|---|
| 298 | |13. Expenses Paid By YOUR Dependent Child for College, Vocational
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|---|
| 299 | Year, Enter the Amount you Contributed To Their Support
|
|---|
| 300 | |Rehabilitation or Training (tuition, books, materials, etc.)
|
|---|
| 301 | Spouse $
|
|---|
| 302 | Child $
|
|---|
| 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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