| 1 | English French Notes Complete/Exclude
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| 2 | 14. Was Child Permanently And Totally Disabled Before
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| 3 | |15. If Child is Between 18 and 23 Years Of Age, Did Child
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| 4 | The Age Of 18?
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| 5 | | Attend School Last Calendar Year?
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| 6 | IIB - FINANCIAL DISCLOSURE
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| 7 | You are not required to provide the financial information in this Section. However, current law may require VA to consider your
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| 8 | household financial situation to determine your eligibility for enrollment and/or cost-free care of your nonservice-connected
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| 9 | (NSC) conditions. If you are 0% SC noncompensable or NSC (and are not an Ex-POW, WWI veteran or VA pensioner) and your
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| 10 | annual household income (or combined income net worth) exceeds the established threshold, you must agree to pay VA co-payments
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| 11 | for care of your NSC conditions to be eligible for enrollment. See Section III - Consent and Signature
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| 12 | YES, I WILL PROVIDE SPECIFIC INCOME AND/OR ASSET INFORMATION TO HAVE ELIGIBILITY FOR CARE DETERMINED. Complete all
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| 13 | sections below that apply to you with last calendar year's information. Sign and date the application.
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| 14 | NO, I DO NOT WISH TO PROVIDE MY DETAILED FINANCIAL INFORMATION. I understand I will be assigned the appropriate enrollment
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| 15 | priority based on nondisclosure of my financial information. By checking NO and signing below, I am agreeing to pay the
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| 16 | applicable VA co-payment. Sign and date the application.
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| 17 | IIC - PREVIOUS CALENDAR YEAR GROSS ANNUAL INCOME OF VETERAN, SPOUSE AND DEPENDENT CHILDREN
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| 18 | 1. What Was Your Gross Annual Income From Employment (wages, bonuses,
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| 19 | tips, etc), As Well as Income From Your Farm, Ranch, Property or Business
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| 20 | 2. List Other Income Amounts (Social Security, compensation, pension,
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| 21 | interest, dividends) Exclude Welfare.
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| 22 | 3. Was Income From Your Farm, Ranch, Property or Business (if yes, refer to page 2, Section IIC of the instructions.)
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| 23 | IID - DEDUCTIBLE EXPENSES
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| 24 | 1. Non-Reimbursed Medical Expenses Paid By You or Your Spouse (payments for doctors, dentists, drugs,
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| 25 | Medicare, health insurance, hospital and nursing home)
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| 26 | 2. Amount You Paid Last Calendar Year For Funeral And Burial Expenses For Deceased Spouse or Dependent
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| 27 | Child (also enter spouse or child's information in Section IIA)
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| 28 | 3. Amount You Paid Last Calendar Year For YOUR College or Vocational Educational Expenses (tutition, books,
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| 29 | fees, materials, etc.) Do Not List Your Dependent's Educational Expenses.
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| 30 | IIE - NET WORTH
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| 31 | 1. Cash, Amount In Bank Accounts (checking and savings accounts, certificates of deposit,
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| 32 | individual retirement accounts, etc.)
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| 33 | 2. Market Value Of Land And Buildings MINUS Mortgages And Liens. Do NOT COUNT YOUR
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| 34 | PRIMARY HOME. Include value of farm, ranch, or business assets.
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| 35 | 3. Stocks And Bonds AND Value Of Other Property or Assets (art, rare coins, etc.) MINUS
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| 36 | The Amount You Owe On These Items. Exclude household effects and family vehicles.
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| 37 | SECTION III
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| 38 | CONSENT TO RELEASE INFORMATION
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| 39 | my medical records (including information relating to the diagnosis, treatment of other therapy for the conditions of
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| 40 | substance abuse, alcoholism or alcohol abuse, sickle cell anemia, or testing for or infection with the human immunodeficiency
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| 41 | virus) to the contractor of any health plan contract under which I am apparently eligible for medical care or payment of the
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| 42 | expense of care or to any other party against whom liability is asserted. I understand that I may revoke this authorization
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| 43 | at any time, except to the extent that action has already been taken in reliance on it. Without my express revocation, this
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| 44 | consent will automatically expire when all action arising from VA's claim for reimbursement for my medical care has been
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| 45 | completed. I authorize payment of medical benefits to VA for any services for which payment is accepted.
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| 46 | SOCIAL SECURITY NUMBER
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| 47 | | DATE OF BIRTH
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| 48 | SIGNATURE OF PATIENT
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| 49 | III - CONSENT AND SIGNATURE
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| 50 | ALL APPLICANTS MUST SIGN AND DATE THE APPLICATION FOR HEALTH BENEFITS
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| 51 | clearance requirements of section 3507 of the Paperwork Reduction Act of 1995. We may not conduct or sponsor, and you are
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| 52 | not required to respond to, a collection of information unless it displays a valid OMB number. We anticipate that the
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| 53 | time expended by all individuals who must complete this form will average 20 minutes. This includes the time it will take
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| 54 | to read instructions, gather the necessary facts and fill out the form.
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| 55 | Privacy Act Information: The VA is asking you to provide the information on this form under Title 38, United States Code,
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| 56 | sections 1710, 1712, and 1722 in order for VA to determine your eligibility for medical benefits. The information you supply
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| 57 | may be verified through a computer-matching program. VA may disclose the information that you put on the form as permitted by
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| 58 | law. VA may make a
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| 59 | disclosure for: civil or criminal law enforcement, congressional communications,
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| 60 | epidemiological or research studies, the collection of money owed to the United States, litigation in which the United States
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| 61 | is a party or has interest, the administration of VA programs and delivery of VA benefits, verification of identity and status,
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| 62 | and personnel administration. You do not have to provide the information to VA, but if you don't, we will be unable to
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| 63 | process your request and serve your medical needs. Failure to furnish the information will not have any affect on any other
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| 64 | benefits to which you may be entitled. If you give VA your Social Security Number, VA will use it to administer your VA
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| 65 | benefits, to identify veterans and persons claiming or receiving VA benefits and their records, and for other purposes
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| 66 | authorized or required by law.
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| 67 | CO-PAYMENT NOTICE: If you are a 0% service-connected noncompensable or a nonservice-connected veteran (and are not an
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| 68 | Ex-POW, WWI veteran or VA pensioner) AND your household income (or combined income and net worth) exceeds the established
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| 69 | threshold, you may be eligible for enrollment only if you agree to pay VA co-payments for treatment of your NSC conditions.
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| 70 | By signing this application you are agreeing to pay the applicable VA co-payment if required by law.
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| 71 | I CERTIFY THE FOREGOING STATEMENT(S) ARE TRUE AND CORRECT TO THE BEST OF MY KNOWLEDGE AND ABILITY.
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| 72 | SIGN HERE
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| 73 | HEALTH SERVICES
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| 74 | 10-10EZ Application Quick Lookup --
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| 75 | At the prompt, you may enter any one of the following:
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| 76 | (1) Application ID
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| 77 | (2) Web Submission ID
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| 78 | Hyphens must appear just as received from
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| 79 | the On-Line 1010-EZ application.
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| 80 | (3) Applicant Name
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| 81 | No space between last and first name.
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| 82 | (4) Applicant SSN
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| 83 | Must be entered as nnn-nn-nnnn.
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| 84 | App #:
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| 85 | Web ID:
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| 86 | Date Rec'd:
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| 87 | Applicant:
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| 88 | Vet Type:
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| 89 | Vet new to Vista?:
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| 90 | Financial Disclosure:
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| 91 | Expect copy from vet?:
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| 92 | Review start date:
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| 93 | Print date:
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| 94 | Sign date:
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| 95 | File date:
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| 96 | Inactivate date:
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| 97 | Appt. Requested:
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| 98 | e-mail Address:
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| 99 | Comments --
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| 100 | NEXT-OF-KIN
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| 101 | LAST NAME
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| 102 | FIRST NAME
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| 103 | MIDDLE NAME
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| 104 | SUFFIX NAME
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| 105 | AMERICAN SAMOA
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| 106 | DISTRICT OF COLUMBIA
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| 107 | FEDERATED STATES OF MICRONESIA
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| 108 | MARSHALL ISLANDS
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| 109 | NORTHERN MARIANA ISLANDS
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| 110 | PALAU (TRUST TERRITORY)
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| 111 | PUERTO RICO
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| 112 | VIRGIN ISLANDS
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| 113 | APPLICANT STATE
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| 114 | WORK PHONE AREA CODE
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| 115 | WORK PHONE NUMBER
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| 116 | WORK PHONE EXTENSION
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| 117 | HOME PHONE AREA CODE
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| 118 | HOME PHONE NUMBER
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| 119 | EMPLOYER PHONE AREA CODE
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| 120 | EMPLOYER PHONE NUMBER
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| 121 | EMPLOYER PHONE EXTENSION
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| 122 | WIDOW/WIDOWER
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| 123 | UNKNOWN/NO PREFERENCE
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| 124 | SC 50-100%
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| 125 | SC <50%
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| 126 | SC 0%
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| 127 | PURPLE HEART
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| 128 | MIL. RETIREE
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| 129 | SOCIAL SECURITY NUMBER
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| 130 | DATE OF BIRTH
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| 131 | 'Accept Field'
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| 132 | Printed
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| 133 | Signed
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| 134 | Filed
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| 135 | Inactivated
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| 136 | Sorry, that data element cannot be 'Accepted' for 'Filing'.
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| 137 | After filing this Application to VistA, use Register a Patient
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| 138 | or Patient Enrollment to enter/update data as needed.
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| 139 | Sorry, that data element must be 'Accepted' for this Applicant.
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| 140 | After filing this Application to VistA, the Registration options
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| 141 | can be used to modify data as needed.
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| 142 | After filing this Application to VistA, Integrated Billing users
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| 143 | can modify the data using the 'Process Insurance Buffer' option.
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| 144 | Sorry, that data element has been Updated and must be 'Accepted'
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| 145 | for this Applicant.
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| 146 | 'Accept All'
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| 147 | 'Clear All'
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| 148 | Sorry, the 'Clear All' action cannot be used for this new patient.
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| 149 | It is recommended that all data elements be 'Accepted' for 'Filing'.
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| 150 | After filing the Application to VistA, the Registration options
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| 151 | can be used to modify data.
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| 152 | 'Reset to New'
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| 153 | Application has been Reset to New...
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| 154 | Unreviewed
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| 155 | 'Verify Signature'
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| 156 | Previously Signed
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| 157 | Applicant signature is verified...
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| 158 | Unsigned
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| 159 | Previously Filed
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| 160 | Previously Inactivated
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| 161 | Application has been closed/inactivated...
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| 162 | Filing 10-10EZ Data (Appl. #
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| 163 | ) to VistA
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| 164 | 10-10EZ data is being filed as a background job.
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| 165 | Task #:
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| 166 | 'Print Data'
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| 167 | Data Print queued to background...
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| 168 | 'Update Field'
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| 169 | Sorry...the selected data element cannot be 'Updated'.
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| 170 | No punctuation is allowed other than
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| 171 | in a hyphenated name.
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| 172 | No punctuation or numerics are allowed.
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| 173 | AREA CODE
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| 174 | Use format nnn-nnnn. Example: 222-1234
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| 175 | Use up to 5 digits; no other characters. Example: 12345
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| 176 | Use format nnn-nnn-nnn. Example: 222-33-4444
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| 177 | Sorry... that SSN is already used by another person
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| 178 | in the INCOME PERSON File (#408.13). Try again.
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| 179 | SID
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| 180 | VISTA AUTOMATION
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| 181 | ADDITIONAL CHILD
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| 182 | Services Request
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| 183 | Submit ID
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| 184 | Email Address
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| 185 | Version #
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| 186 | Veteran To Mail
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| 187 | Provide
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| 188 | Details
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| 189 | Appointment Request
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| 190 | APPLICANT LAST NAME
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| 191 | APPLICANT FIRST NAME
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| 192 | APPLICANT MIDDLE NAME
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| 193 | APPLICANT SUFFIX NAME
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| 194 | RATED PERCENTAGE
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| 195 | RETIRED FROM MILITARY
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| 196 | Receipt Confirmation for:
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| 197 | Sent from:
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| 198 | Site msg #:
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| 199 | 1010EZ CONFIRMATION for SID
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| 200 | GMT Threshold Lookup by Zip Code or City
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| 201 | ZIP Code
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| 202 | Zip Code is invalid; there is no GMT Threshold associated with this value.
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| 203 | Enter the ZIP code [5 - 12 characters] that you wish to select.
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| 204 | GMT Thresholds not found for entered ZIP code.
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| 205 | GMT Threshold is not available for entered ZIP code.
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| 206 | County Name:
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| 207 | State:
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| 208 | FIPS Code
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| 209 | # in Household
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| 210 | GMT Threshold
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| 211 | EAS MTOVERRIDE
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| 212 | Means Test Alert
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| 213 | A Means Test is required or needs to be completed.
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| 214 | Please perform MEANS TEST or instruct patient
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| 215 | to report for Means Test interview.
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| 216 | >> A future appointment cannot be made at this time.
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| 217 | >> Override Key in Effect.
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| 218 | >> This action may not be completed at this time.
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| 219 | >> Check-Out ONLY. Do NOT Check-In (CI) a walk-in appointment
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| 220 | You will not be able to check-out the appt. if you do so.
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| 221 | AUTOMATED MT LETTERS GENERATOR
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| 222 | The prior processing date is not available. A default date
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| 223 | will be used.
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| 224 | Ok to continue?
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| 225 | Select new start date:
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| 226 | >> The Means Test Letter search has been run for today.
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| 227 | Auto MT Letters: This process is already running,
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| 228 | This process is already running, please try again later
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| 229 | Auto-Letters Search completed:
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| 230 | >> Processing date
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| 231 | in progress <<
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| 232 | Automated Means Test Letter Generator Statistics
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| 233 | Beginning Processing Date:
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| 234 | Ending Processing Date:
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| 235 | -day Letters:
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| 236 | Day Letter Totals:
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| 237 | AUTO MT LETTER RESULTS -
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| 238 | AUTOMATED MT LETTERS
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| 239 | Filter letters by Preferred Facility?
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| 240 | Enter 'YES' to limit letters to a specific Facility or 'NO' to print all letters
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| 241 | No valid processing date could be found for
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| 242 | -day letters for
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| 243 | Please select another date.
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| 244 | To re-print
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| 245 | the Search/Processing date of
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| 246 | Please note: ALL
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| 247 | -day letters for this processing date will print
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| 248 | Enter 'YES' to use the
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| 249 | date. Enter 'NO' to select a different date.
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| 250 | Do you wish to use this date?
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| 251 | Select the date for the letters you wish to re-print.
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| 252 | Enter re-print date:
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| 253 | Select letter type
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| 254 | Select the type of letter to re-print
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| 255 | EAS MT LETTERS REPRINT
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| 256 | Reprint canceled
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| 257 | Letters queued, [
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| 258 | ...Gathering letters to re-print...
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| 259 | >> No letters found to reprint for these parameters.
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| 260 | Select Patient Letter status entry to reprint
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| 261 | The Prohibit flag is set for this patient
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| 262 | Patient is deceased
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| 263 | Select Processing Date:
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| 264 | Select the letter processing date for this patient
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| 265 | A Means Test has already been returned by this patient
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| 266 | Patient's Means Test is no longer required
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| 267 | There are no letters to re-print for this patient
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| 268 | Select letter type to re-print
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| 269 | EAS MT RERUN SINGLE LETTER
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| 270 | Available Processing Dates:
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| 271 | ERROUT(1)
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| 272 | Unable to generate entry in EAS MT PATIENT STATUS File, #713.1
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| 273 | NO LONGER REQUIRED
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| 274 | The following issues were reported by the Means Test Letter Search Process:
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| 275 | MT LETTERS SEARCH ISSUES -
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| 276 | Select the type of letter to print
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| 277 | EAS MT LETTERS PRINT JOB
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| 278 | Letters canceled!
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| 279 | Letters queued! [
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| 280 | ...Gathering letters to print...Please wait
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| 281 | ...Printing letters...
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| 282 | Letters to print:
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| 283 | Letters where the print date has not reached:
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| 284 | The following letters were found but not printed for the following reasons:
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| 285 | Incomplete/Bad Addr :
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| 286 | Deceased :
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| 287 | MT Changed:
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| 288 | Prohibit flag set:
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| 289 | Not a User Enrollee:
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| 290 | Not a User Enrollee of this facility:
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| 291 | Total Letters Processed:
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| 292 | (MT not returned)
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| 293 | Print Letter Results
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| 294 | STOPPED BY USER
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| 295 | 4///YES;5///TODAY;7///MT 'OWNED' BY ANOTHER FACILITY;9///NO;12///NO;18///NO
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| 296 | MEANS TEST ANNIVERSARY DATE:
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| 297 | Dear
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| 298 | Mr./Ms.
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| 299 | VA Medical Center
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| 300 | Enclosure
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| 301 | TEST LETTER (DO NOT MAIL!)
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| 302 | THIS IS A TEST LETTER STREET ADDRESS
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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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