English French Notes Complete/Exclude Weapons Total # : Firearms : Knives/Hatchets/Clubs : Explosives : Other : DISTURBANCES Total # : Demonstrations : Employee Threat : Smoking Violation : Unauthorized Photograph : MANSLAUGHTER/MURDER Total # : Manslaughter/Murder/Negligent : Manslaughter/Murder/Non-Neg. : NON-CRIMINAL INVESTIGATIONS Total # : Government Veh. Accident : Assist Law Officer : Alarm Response : Information Only : OTHER OFFENSES Total # : Arson : Arson $ Damage : Possession of Stolen Property : Receive/Sell Stolen Property : Suicide : Suicide Attempt : RAPES Total # : Attempted Rape : Forcible Rape : ROBBERY Total # : STOPS & ARRESTS Total # : Stops for Questioning : Package Stops : Non-Package Stops : THEFTS Total # : Coin-Operated Machines : Total $ Loss : Total $ Recovery : Actual Drug Thefts : Controlled Substance : Non-Controlled Substance : Attempted Drug Thefts : Total Drug Thefts : Total $ Recovered : Government Property : Personal Property : Motor Vehicles : Government Motor Vehicle : Gov't Vehicles Recovered : Private Motor Vehicle : Private Veh's Recovered : VICE SOLICITING Total # : Forgery : Gambling : Sexual Misconduct : VIOLATION CHARGES Total # : USDC Notice Total # : The report will be forwarded to the national database. You may now enter any additional people you would like to forward this report to. XXX@Q-VAP.VA.GOV ...Forwarded to National Database. VICE SOLICITING Total # : Is this a courtesy or USDC violation Enter C for COURTESY or V for USDC violation The program is now exiting! Do you want to add a new violation DATE/TIME OF OFFENSE Enter the date and time of the offense. Future dates not allowed. Court Date must be after the Date/Time of Offense! NO EXISTING VIOLATIONS FOR EXISTING VIOLATIONS FOR OFFENSE CHARGED Data Validation in progress No Date/Time Received. No Date/Time of Offense. No Investigating Officer. No Classification Code. No Type for this Classification Code. No Sub-Type for this Type. This report must have the above before it can be completed. Report Completed. Select Vehicle Registration: VIOLATION #: PRINT USDC VIOLATION NOTICE OFFENSE CHARGED: OFFENSE DESCRIPTION: OFFENDER: RECORD DOESN'T EXIST. DRIVER'S LICENSE #: TAG # & STATE: VEHICLE COLOR: YEAR: COURT DATE: * * * VIOLATION NOTICE * * * * * * COURTESY VIOLATION NOTICE * * * Enter the Decal # (ex. 9999) NO MATCH FOUND. Do you want to add this decal # DECAL COLOR: VEHICLE MAKE: ASSIGNED PARKING SPACE: CAR POOL MEMBER: READY TO UPDATE Another user is editing this record! This decal # is already in the Police Registration Log. Do you want to edit this registration Select OFFICER This officer is not a current police officer. WORKLOAD REPORT ALL OFFICERS Checking SOUNDEX for matches. No matches found. Do you still want to add this entry: NO// NnYy^? Answer NO to stop the addition of as a new master name index person. Answer YES to add, a '^' will be taken as a NO. Print 7079's for: There are no 7079's to be printed! Want only those that have not yet been printed ID Card Number: (1) Veterans Name |(2) ID Number | Period of Validity |DATE OF ISSUE | CONDITIONS FOR WHICH SERVICES ARE REQUESTED (DESCRIPTION OF DISABILITY) Name and Address of Fee Participant AUTHORIZATION #: AUTHORIZATION REMARKS (5) STATE CODE | (6) COUNTY CODE | (7) TYPE OF | (8) YEAR OF BIRTH | (9) WAR | (10) PURPOSE | STATION OF JURISDICTION Veterans Administration SHORT TERM - 1 HOME NURSING - 2 ID CARD STATUS - 3 | APPROVED BY (Name and Title) TELEPHONE: Information On Veterans Administration Program Acceptance of this request to render the prescribed services will constitute an agreement which is subject to the following: I. SERVICES. If services are not initiated, please return this document to the Station of Jurisdiction with a brief explanation. Unless approved by the VA, services are limited in type and extent to those shown. II. PERIOD OF VALIDITY. Service must be performed within the period of validity indicated. If a longer time is needed, please request an extension. III. REPORTS. Clinical reports are required when an examination only has been requested. Please submit reports promptly to the Station Of Jurisdiction. IV. STATEMENT OF ACCOUNTS. Submit a Statement of Account in your usual manner. Your statement must include: (1) Patient's Name; (2) Identification NO.; (3) Treatment (CPT) and Dates Rendered; and (4) Fees. V. FEES. Fees claimed may not exceed those made to the general public for like services. VI. PAYMENT. Payment by the VA for services rendered and approved is payment in full. VII. HOSPITALIZATION. When a need for hospital care is indicated, please call the Station of Jurisdiction for assistance in admitting the veteran to a VA hospital. VIII. INQUIRIES. Additional information when required may be obtained by contacting the Station Of Jurisdiction. VA Form 10-7079 ELIGIBILITY HAS NOT BEEN DETERMINED NOR PENDING, CANNOT ENTER AN AUTHORIZATION. VETERAN HAS A DISHONORABLE DISCHARGE, ONLY ELIGIBLE FOR AGENT ORANGE EXAM. NOT ELIGIBLE FOR BENEFITS. Want to Print 7079 for this patient now Is this vendor information correct FBAA ESTABLISH VENDOR You must contact a vendorizing clerk or supervisor to update this record! Vendor flagged for updating! Are you sure you want to update this Vendor in the FMS and Central Fee vendor files Will NOT be Updated This option should only be used to update the FMS and Central Fee vendor files in Austin with the appropriate information. (NOTE: The vendor may not exist in the FMS vendor file, or may exist, but the information in the FMS vendor file does not reflect accurate information.) Use of this option should update the FMS system to reflect what is currently in the DHCP system. Information at all other VA Medical Centers using this vendor will also be updated. Sure you want to DELETE this batch Batch Deleted. Obligation Number: Do you want to change the Obligation Number Select Obligation Number: DUZ and DUZ(0) must be defined as a valid user to run the batch purge. You must have programmer access (DUZ(0)='@') before running the batch purge. There are no batches finalized !! This option is used to purge Fee Basis batch numbers for a time frame in the past. Do you want to continue if you wish to proceed with Fee Basis batch number purging! Purge batch #'s PRIOR to date : *** BEGIN FEE BASIS BATCH NUMBER PURGE *** There are no batch numbers to purge for this time frame !! This option has purged batch numbers finalized prior to *** FEE BASIS BATCH NUMBER PURGE FINISHED *** Unknown User FBAA BATCH PURGE Do you want to print ALL Fee Basis Batch Status': CLERK CLOSED SUPERVISOR CLOSED FORWARDED TO PRICER ASSIGNED PRICE REVIEWED AFTER PRICER Select STATUS to print Do you want to select another STATUS: FBSTAT( MEDICAL & STAT PAYMENTS HOMETOWN PHARMACY PAYMENTS TRAVEL PAYMENTS CH/CNH STATUS OF BATCHES BATCH # BATCH TYPE DATE OPENED No payments in Batch yet! No Payments in Batch yet! Want to review batch If you want a detail list of each payment line, answer otherwise press Return key Do you still want to close Batch Batch Closed ('*' Reimbursement to Patient '+' Cancellation Activity) ('#' Voided Payment) Batch # Voucher Date Vendor Name Vendor ID Invoice # Date Rec'd. SVC DATE CPT-MOD SERVICE PROVIDED FPPS CLAIM FPPS LINE ADJ CODE ADJ AMOUNT RX DATE RX # '+' Represents Cancellation Activity Travel Amount Invoice #: FPPS Claim ID: FPPS Line: ('*' Reimbursement to Veteran '+' Cancellation Activity) Batch Number Dt Inv Rec'd FR DATE TO DATE CLAIMED PAID Dx: Proc: Date Paid: >>>Amount paid altered to $ on the Fee Payment Voucher document.<<< >>>Check cancelled on: Check WILL be replaced. Check WILL be re-issued. Check WILL NOT be replaced. Patient has never been assigned ID Card! Current ID Card: Date Issued: No previous ID Cards! Does not currently have ID Card! Date/Time Changed Old Card # Person Who Changed Reason For Change There are no Invoices Pending completion! Fee Site Parameters must be Initialized! Invoice is Complete Totals: $ Vendor: Vendor ID: Patient ID: FPPS Line Item: Drug Name Amt Claimed Generic Drug Substituted: Pharmacy Remarks: Hit Return to accept default dispensing fee or enter a dollar amount between .01 and 20 **Payment is for emergency treatment under 38 U.S.C. 1725. Amount Paid cannot be greater than the Amount Claimed This option is restricted to holders of the 'FBAASUPERVISOR' security key. The last user to enter/edit this Authorization was FPPS CLAIM ID: Invoice: Service selected for that date already in system. Do you want to add another service for the SAME DATE You must use the 'EDIT PAYMENT' option to edit the service previously entered for that date. Want to edit it Warning, you can only enter more line(s)! This Batch already has the maximum number of Payments! Will any line items in this invoice be for contracted services Answering no indicates interest will not be paid for any line items. Patient: No Address information for this patient! Patient's Permanent address: Address Line Zip: County Want to edit Permanent Address data Payment is for a contracted service so fee schedule does not apply. However, f ee schedule amount is $ from the Unable to determine a FEE schedule amount. Therefore, fee schedule amount reduced to $ #################### #################### #################### #################### #################### #################### #################### #################### #################### #################### #################### #################### #################### #################### ####################