English	French	Notes	Complete/Exclude
14. Was Child Permanently And Totally Disabled Before			
|15. If Child is Between 18 and 23 Years Of Age, Did Child			
The Age Of 18?  			
| Attend School Last Calendar Year?  			
IIB - FINANCIAL DISCLOSURE			
You are not required to provide the financial information in this Section. However, current law may require VA to consider your			
household financial situation to determine your eligibility for enrollment and/or cost-free care of your nonservice-connected			
(NSC) conditions. If you are 0% SC noncompensable or NSC (and are not an Ex-POW, WWI veteran or VA pensioner) and your			
annual household income (or combined income net worth) exceeds the established threshold, you must agree to pay VA co-payments			
for care of your NSC conditions to be eligible for enrollment.  See Section III - Consent and Signature			
 YES, I WILL PROVIDE SPECIFIC INCOME AND/OR ASSET INFORMATION TO HAVE ELIGIBILITY FOR CARE DETERMINED. Complete all			
sections below that apply to you with last calendar year's information.  Sign and date the application.			
 NO, I DO NOT WISH TO PROVIDE MY DETAILED FINANCIAL INFORMATION. I understand I will be assigned the appropriate enrollment			
priority based on nondisclosure of my financial information. By checking NO and signing below, I am agreeing to pay the			
applicable VA co-payment.  Sign and date the application.			
IIC - PREVIOUS CALENDAR YEAR GROSS ANNUAL INCOME OF VETERAN, SPOUSE AND DEPENDENT CHILDREN			
1. What Was Your Gross Annual Income From Employment (wages, bonuses,			
tips, etc), As Well as Income From Your Farm, Ranch, Property or Business			
2. List Other Income Amounts (Social Security, compensation, pension,			
interest, dividends) Exclude Welfare.			
3. Was Income From Your Farm, Ranch, Property or Business (if yes, refer to page 2, Section IIC of the instructions.)  			
IID - DEDUCTIBLE EXPENSES			
1. Non-Reimbursed Medical Expenses Paid By You or Your Spouse (payments for doctors, dentists, drugs,			
Medicare, health insurance, hospital and nursing home)			
2. Amount You Paid Last Calendar Year For Funeral And Burial Expenses For Deceased Spouse or Dependent			
Child (also enter spouse or child's information in Section IIA)			
3. Amount You Paid Last Calendar Year For YOUR College or Vocational Educational Expenses (tutition, books,			
fees, materials, etc.) Do Not List Your Dependent's Educational Expenses.			
IIE - NET WORTH			
1. Cash, Amount In Bank Accounts (checking and savings accounts, certificates of deposit,			
individual retirement accounts, etc.)			
2. Market Value Of Land And Buildings MINUS Mortgages And Liens.  Do NOT COUNT YOUR			
PRIMARY HOME.  Include value of farm, ranch, or business assets.			
3. Stocks And Bonds AND Value Of Other Property or Assets (art, rare coins, etc.) MINUS			
The Amount You Owe On These Items. Exclude household effects and family vehicles.			
SECTION III			
CONSENT TO RELEASE INFORMATION			
my medical records (including information relating to the diagnosis, treatment of other therapy for the conditions of			
substance abuse, alcoholism or alcohol abuse, sickle cell anemia, or testing for or infection with the human immunodeficiency			
virus) to the contractor of any health plan contract under which I am apparently eligible for medical care or payment of the			
expense of care or to any other party against whom liability is asserted. I understand that I may revoke this authorization			
at any time, except to the extent that action has already been taken in reliance on it. Without my express revocation, this			
consent will automatically expire when all action arising from VA's claim for reimbursement for my medical care has been			
completed.  I authorize payment of medical benefits to VA for any services for which payment is accepted.			
SOCIAL SECURITY NUMBER  			
| DATE OF BIRTH  			
SIGNATURE OF PATIENT			
III - CONSENT AND SIGNATURE			
ALL APPLICANTS MUST SIGN AND DATE THE APPLICATION FOR HEALTH BENEFITS			
clearance requirements of section 3507 of the Paperwork Reduction Act of 1995. We may not conduct or sponsor, and you are			
not required to respond to, a collection of information unless it displays a valid OMB number.  We anticipate that the			
time expended by all individuals who must complete this form will average 20 minutes. This includes the time it will take			
to read instructions, gather the necessary facts and fill out the form.			
Privacy Act Information: The VA is asking you to provide the information on this form under Title 38, United States Code, 			
sections 1710, 1712, and 1722 in order for VA to determine your eligibility for medical benefits. The information you supply			
may be verified through a computer-matching program. VA may disclose the information that you put on the form as permitted by			
law. VA may make a 			
 disclosure for: civil or criminal law enforcement, congressional communications, 			
epidemiological or research studies, the collection of money owed to the United States, litigation in which the United States			
is a party or has interest, the administration of VA programs and delivery of VA benefits, verification of identity and status,			
and personnel administration. You do not have to provide the information to VA, but if you don't, we will be unable to 			
process your request and serve your medical needs. Failure to furnish the information will not have any affect on any other 			
benefits to which you may be entitled. If you give VA your Social Security Number, VA will use it to administer your VA 			
benefits, to identify veterans and persons claiming or receiving VA benefits and their records, and for other purposes 			
authorized or required by law.			
CO-PAYMENT NOTICE: If you are a 0% service-connected noncompensable or a nonservice-connected veteran (and are not an			
Ex-POW, WWI veteran or VA pensioner) AND your household income (or combined income and net worth) exceeds the established			
threshold, you may be eligible for enrollment only if you agree to pay VA co-payments for treatment of your NSC conditions.			
By signing this application you are agreeing to pay the applicable VA co-payment if required by law.			
I CERTIFY THE FOREGOING STATEMENT(S) ARE TRUE AND CORRECT TO THE BEST OF MY KNOWLEDGE AND ABILITY.			
SIGN HERE   			
HEALTH SERVICES			
10-10EZ Application Quick Lookup --			
At the prompt, you may enter any one of the following:			
(1) Application ID			
(2) Web Submission ID			
             Hyphens must appear just as received from			
             the On-Line 1010-EZ application.			
(3) Applicant Name			
              No space between last and first name.			
(4) Applicant SSN			
             Must be entered as nnn-nn-nnnn.			
App #: 			
Web ID: 			
Date Rec'd: 			
Applicant: 			
Vet Type: 			
Vet new to Vista?:			
Financial Disclosure: 			
Expect copy from vet?:			
Review start date: 			
Print date: 			
Sign date: 			
File date: 			
Inactivate date: 			
Appt. Requested: 			
e-mail Address: 			
Comments --			
NEXT-OF-KIN			
 LAST NAME			
 FIRST NAME			
 MIDDLE NAME			
 SUFFIX NAME			
AMERICAN SAMOA			
DISTRICT OF COLUMBIA			
FEDERATED STATES OF MICRONESIA			
MARSHALL ISLANDS			
NORTHERN MARIANA ISLANDS			
PALAU (TRUST TERRITORY)			
PUERTO RICO			
VIRGIN ISLANDS			
APPLICANT STATE			
 WORK PHONE AREA CODE			
 WORK PHONE NUMBER			
 WORK PHONE EXTENSION			
 HOME PHONE AREA CODE			
 HOME PHONE NUMBER			
 EMPLOYER PHONE AREA CODE			
 EMPLOYER PHONE NUMBER			
 EMPLOYER PHONE EXTENSION			
WIDOW/WIDOWER			
UNKNOWN/NO PREFERENCE			
SC 50-100%			
SC <50%			
SC 0%			
PURPLE HEART			
MIL. RETIREE			
 SOCIAL SECURITY NUMBER			
 DATE OF BIRTH			
'Accept Field'			
Printed			
Signed			
Filed			
Inactivated			
Sorry, that data element cannot be 'Accepted' for 'Filing'.			
After filing this Application to VistA, use Register a Patient 			
or Patient Enrollment to enter/update data as needed.			
Sorry, that data element must be 'Accepted' for this Applicant.			
After filing this Application to VistA, the Registration options			
can be used to modify data as needed.			
After filing this Application to VistA, Integrated Billing users			
can modify the data using the 'Process Insurance Buffer' option.			
Sorry, that data element has been Updated and must be 'Accepted'			
for this Applicant.			
'Accept All'			
'Clear All'			
Sorry, the 'Clear All' action cannot be used for this new patient.			
It is recommended that all data elements be 'Accepted' for 'Filing'.			
After filing the Application to VistA, the Registration options			
can be used to modify data.			
'Reset to New'			
Application has been Reset to New...			
Unreviewed			
'Verify Signature'			
Previously Signed			
Applicant signature is verified...			
Unsigned			
Previously Filed			
Previously Inactivated			
Application has been closed/inactivated...			
Filing 10-10EZ Data (Appl. #			
) to VistA			
10-10EZ data is being filed as a background job.			
Task #: 			
'Print Data'			
Data Print queued to background...			
'Update Field'			
Sorry...the selected data element cannot be 'Updated'.			
No punctuation is allowed other than 			
 in a hyphenated name.			
No punctuation or numerics are allowed.			
AREA CODE			
Use format nnn-nnnn.  Example: 222-1234			
Use up to 5 digits; no other characters.  Example: 12345			
Use format nnn-nnn-nnn.  Example: 222-33-4444			
Sorry... that SSN is already used by another person			
in the INCOME PERSON File (#408.13).  Try again.			
SID 			
VISTA AUTOMATION			
ADDITIONAL CHILD			
Services Request			
Submit ID			
Email Address			
Version #			
Veteran To Mail			
Provide			
Details			
Appointment Request			
APPLICANT LAST NAME			
APPLICANT FIRST NAME			
APPLICANT MIDDLE NAME			
APPLICANT SUFFIX NAME			
RATED PERCENTAGE			
RETIRED FROM MILITARY			
Receipt Confirmation for: 			
Sent from: 			
Site msg #: 			
1010EZ CONFIRMATION for SID 			
GMT Threshold Lookup by Zip Code or City			
ZIP Code			
Zip Code is invalid; there is no GMT Threshold associated with this value.			
Enter the ZIP code [5 - 12 characters] that you wish to select.			
GMT Thresholds not found for entered ZIP code.			
GMT Threshold is not available for entered ZIP code.			
County Name: 			
State: 			
FIPS Code			
# in Household			
GMT Threshold			
EAS MTOVERRIDE			
Means Test Alert			
A Means Test is required or needs to be completed.			
Please perform MEANS TEST or instruct patient			
to report for Means Test interview.			
>> A future appointment cannot be made at this time.			
>> Override Key in Effect.			
>> This action may not be completed at this time.			
>> Check-Out ONLY.  Do NOT Check-In (CI) a walk-in appointment			
   You will not be able to check-out the appt. if you do so.			
AUTOMATED MT LETTERS GENERATOR			
The prior processing date is not available.  A default date			
 will be used.			
Ok to continue? 			
Select new start date: 			
>> The Means Test Letter search has been run for today.			
Auto MT Letters: This process is already running, 			
This process is already running, please try again later			
Auto-Letters Search completed: 			
>> Processing date  			
  in progress <<			
Automated Means Test Letter Generator Statistics			
Beginning Processing Date: 			
Ending Processing Date:    			
-day Letters: 			
 Day Letter Totals:    			
AUTO MT LETTER RESULTS - 			
AUTOMATED MT LETTERS			
Filter letters by Preferred Facility? 			
Enter 'YES' to limit letters to a specific Facility or 'NO' to print all letters			
No valid processing date could be found for 			
-day letters for 			
Please select another date.			
To re-print 			
the Search/Processing date of 			
Please note: ALL 			
-day letters for this processing date will print			
Enter 'YES' to use the 			
 date.  Enter 'NO' to select a different date.			
Do you wish to use this date? 			
Select the date for the letters you wish to re-print.			
Enter re-print date: 			
Select letter type			
Select the type of letter to re-print 			
EAS MT LETTERS REPRINT			
Reprint canceled			
Letters queued, [			
...Gathering letters to re-print...			
>> No letters found to reprint for these parameters.			
Select Patient Letter status entry to reprint			
The Prohibit flag is set for this patient			
Patient is deceased			
Select Processing Date: 			
Select the letter processing date for this patient			
A Means Test has already been returned by this patient			
Patient's Means Test is no longer required			
There are no letters to re-print for this patient			
Select letter type to re-print			
EAS MT RERUN SINGLE LETTER			
Available Processing Dates:			
ERROUT(1)			
Unable to generate entry in EAS MT PATIENT STATUS File, #713.1			
NO LONGER REQUIRED			
The following issues were reported by the Means Test Letter Search Process:			
MT LETTERS SEARCH ISSUES - 			
Select the type of letter to print			
EAS MT LETTERS PRINT JOB			
Letters canceled!			
Letters queued! [ 			
...Gathering letters to print...Please wait			
...Printing letters...			
Letters to print: 			
Letters where the print date has not reached: 			
The following letters were found but not printed for the following reasons:			
Incomplete/Bad Addr :                 			
Deceased :                            			
MT Changed:                           			
Prohibit flag set:                    			
Not a User Enrollee:                  			
Not a User Enrollee of this facility: 			
Total Letters Processed: 			
 (MT not returned)			
 Print Letter Results			
STOPPED BY USER			
4///YES;5///TODAY;7///MT 'OWNED' BY ANOTHER FACILITY;9///NO;12///NO;18///NO			
MEANS TEST ANNIVERSARY DATE: 			
Dear 			
Mr./Ms. 			
VA Medical Center			
Enclosure			
TEST LETTER (DO NOT MAIL!)			
THIS IS A TEST LETTER STREET ADDRESS			
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