English	French	Notes	Complete/Exclude
subtracted is greater than the veteran's copayment then the assets			
will not be reduced.			
Do you wish to edit the LTC copay test			
 * VETERAN MAY BE EXEMPT FROM COPAY IF LTC EPISODE IS DUE TO THIS CONDITION.			
    Service Branch			
      Gulf War			
    Env Contam: 			
     Mil Disab: 			
      Dent Inj: 			
  Purple Heart: 			
 and Spouse			
Residence			
Other Residences/Land/Farm/or Ranch			
Vehicle(s)			
Cash, Stocks, Mutual Funds			
Other Liquid Assets			
Cash			
Stocks, Bonds, Mutual Funds, SEP's			
Current Employment Income			
Income from Farm/Ranch/Business			
Current Income			
Soc. Sec. Retire/Disabil			
Interest/Dividends			
Retirement/Pension Income			
Spouse VA Disabil/Compens			
Unemployment Benefit/Comp			
Other Compensation			
Court Mandated			
Other Income			
Education			
Funeral and Burial			
Rent/Mortgage			
Utilities			
Car Payment Only			
Food			
Non-reimbursed Medical Expenses			
Court-ordered Payments			
Taxes			
LTC copay test cannot be completed.			
...The LTC copay test has been completed with a status of 			
Do you wish to complete the LTC copay test			
Does veteran decline to give income information			
Answer 'Y' or 'N'.			
Enter whether the veteran declines to provide current income information.			
An active spouse exists for this LTC copay test. Married should be 'YES'.			
LTC Copay Test Status			
A reason for exemption must be entered for an Exempt status.			
Does the veteran agree to pay copayments			
Enter in this field whether the veteran agrees to pay the			
LTC copayments.  The veteran must also sign the 1010-EC form			
agreeing to pay the copayments. If the veteran does not agree			
to pay the copayments, the veteran becomes ineligible to			
receive extended care services.			
PRINT 10-10EC			
Veteran is EXEMPT from Long Term Care copayments.			
Reason for Exemption: 			
ERROR:  COULD NOT UPDATE LTC COPAY TEST			
LTC COPAY TEST FOR 			
LTC Copayment Status: 			
   Last Test: 			
 **NEW TEST REQUIRED**			
Patient INELIGIBLE to Receive LTC Services -- Did Not Agree to Pay Copayments			
Reason:			
Assets:			
Agrees to Pay Copayments:			
NO *INELIGIBLE*			
Comment(s):			
** DETAILED LTC COPAY TEST INCOME INFORMATION IS NOT 			
REQUIRED **			
AVAILABLE **			
** LTC COPAY TEST IS NO LONGER REQUIRED, INCOME INFORMATION MAY NOT BE ACCURATE **			
DETAILED LTC COPAY TEST INCOME INFORMATION COULD NOT BE CONVERTED FOR THE			
FOLLOWING RELATIONS ASSOCIATED WITH THIS LTC COPAY TEST:			
THE LTC COPAY TEST WOULD HAVE TO BE EDITED.			
TYPE OF BENEFIT-ENROLLMENT			
APPLICANT OTHER NAME			
CHILD(N)			
Sp.			
QUESTION 			
VistA  : 			
APPLICANT SOCIAL SECURITY NUMBER			
EAS(			
APPLICANT DATE OF BIRTH			
1010EZ data for 			
 was not filed to			
 of File #			
A new record for 			
 could not be created in			
 because Field #			
 produced an error:			
APPLICANT SEX			
MEDICARE PART A EFFECTIVE DATE			
PART A			
MEDICARE PART B EFFECTIVE DATE			
PART B			
MEDICARE CLAIM NUMBER			
SIGNEE ON MEDICARE CARD			
APPLICANT INSURANCE COMPANY			
APPLICANT INSURANCE GROUP CODE			
APPLICANT INSURANCE POLICY HOLDER			
APPLICANT INSURANCE POLICY NUMBER			
SPOUSE INSURANCE COMPANY			
SPOUSE INSURANCE GROUP CODE			
SPOUSE INSURANCE POLICY HOLDER			
SPOUSE INSURANCE POLICY NUMBER			
New Patient record added by ELECTRONIC 10-10EZ.			
Applicant Data			
Application #: 			
Received: 			
Veteran Type: 			
Enter Applicant data as prompted --			
NEW PT. FROM ELECTRONIC 10-10EZ -- IN PROCESS			
Sorry... cannot link to selected Patient.			
Application #			
 is already linked to this Patient,			
and is still in-process.			
One moment please...			
Preparing for data comparison to VistA Patient database...			
EAS EZ 1010EZ INITIAL SCREEN			
Another user is processing that Application... try later.			
EAS EZ 1010EZ REVIEW1			
EAS EZ 1010EZ REVIEW2			
EAS EZ 1010EZ REVIEW3			
EAS EZ 1010EZ REVIEW4			
EAS EZ 1010EZ REVIEW5			
EAS EZ 1010EZ REVIEW6			
IN REVIEW			
PRINTED,PENDING SIG.			
Still filing...			
Application #:			
Applicant:			
Date Rec'd:			
Web ID #:			
Vet Sending Signed Form?: 			
DATA ITEM			
Appointment Requested: 			
Services Requested: 			
Comments: 			
Only two actions require a list line number indentifier --			
AF Accept Field			
AF=n			
 to act on the field shown in line #n.			
UF Update Field			
UF=n			
All other actions act on the Application as a whole,			
so a line number is not used.			
Actions 			
Verify Signature			
File 10-10EZ			
Inactivate			
can be used only once per Application.			
Allowed actions for NEW Applications are:			
Allowed actions for IN REVIEW Applications are:			
Allowed actions for PENDING SIGNATURE Applications are:			
Allowed actions for SIGNED Applications are:			
Allowed actions for FILED Applications are:			
There are no allowed actions for an INACTIVATED Application.			
LZ  Link to Patient File			
The veteran associated with a NEW Application must be 'linked' to			
the VistA Patient database.			
VistA Patient Lookup function is employed to match the applicant			
to an existing Patient OR to establish a new Patient record.			
AF  Accept Field			
The 10-10 EZ data element on line #n is 'accepted' for later filing			
into the VistA Patient database.			
Using this action on a previously 'accepted' data element,			
removes the 'accepted' indicator.			
AZ  Accept All			
All 10-10 EZ data element are 'accepted' for later filing into			
CZ  Clear All			
The 'accepted' indicator is removed from any fields previously			
RZ  Reset to New			
The Application is returned to the 'New' processing status.			
It can be re-matched to the VistA database.			
IZ  Inactivate			
Once the Application is inactivated, it will no longer be available			
for processing.			
Use this action only if the Application is deemed invalid or is being			
replaced by a new Application.			
PZ  Print 10-10EZ			
Once the 10-10EZ is Printed, actions of Accept Field, Accept All,			
Clear All, and Update Field can no longer be used.			
The 10-10EZ form is printed using all 'accepted' data. 			
VistA Patient data is used for any fields not 'accepted'.			
Printing must be queued to a valid print device.			
VZ  Verify Signature			
The user verifies that the Applicant's signature appears on a			
UF  Update Field			
The 10-10 EZ data element on line #n can be overwritten by the user for			
later filing into VistA.			
This action should be used to enter the Applicant's hand-written			
changes to the signed 10-10EZ.			
FZ  File 10-10EZ			
All 'accepted' data elements on the 10-10EZ are filed to the			
VistA Patient database.			
Use this action with caution -- 10-10EZ data elements will overwrite			
any existing data in Vista.			
10-10EZ Application Processing --			
Select Applications to View			
PRINTED, PENDING SIG.			
Application Status: 			
Please wait while processing...			
Vet			
Applications not yet filed to the Patient database.			
Select an Application to view.			
No Applications meet the selection criteria. 			
Application being processed by another user.			
Try again late.....			
VALM STACK			
 not allowed for this 			
Do not select a slave device for output.			
This output requires a 132 column output printer.			
1010EZ PRINT			
The applicant has not been linked to the PATIENT File, #2			
This application has not been reviewed			
This application has already been closed, thE VA10-10EZ cannot be printed			
The VA10-10EZ for 			
WEB submission ID: 			
could not be printed for the following reason(s): 			
OMB APPROVED NO. 2900-0091 / Est. Burden Avg. 20 min.			
APPLICATION FOR HEALTH BENEFITS			
APPLICATION FOR HEALTH BENEFITS, Continued			
AUTOMATED VA FORM 10-10EZ APR 1998			
1A. Type of Benefits Applied For:  			
1B. If Applying For Health Services, Which VA Medical Center or Outpatient Clinic Do You Prefer 			
|3. Other Names Used			
5. Social Security Number			
|6. Claim Number			
|7. Date of Birth			
9A. Current Mailing Address			
|10. Home Telephone Number 			
|11. Work Telephone Number 			
12. Current Marital Status: 			
13A. Last Branch of Service			
|13B. Last Entry Date			
|13C.Last Discharge Date			
|13D. Discharge Type			
|13E. Military Service Number			
14. Answer Yes or No for the Following Questions			
Are You a Purple Heart Award Recipient 			
Are You a Former Prisoner of War 			
Do You Have a Military Dental Injury			
Do You Have a VA Service Connected Rating 			
Do You Have a Spinal Cord Injury 			
If Yes, What is Your Rated Percentage 			
Are You Eligible for MEDICAID			
Are You Receiving a VA Pension: 			
Are You Enrolled in MEDICARE Hospital Insurance Part A			
Are You Retired From The Military: 			
Was Your Retirement The Result Of a Disability: 			
Were You Regularly Retired (20+yrs.)			
Were You Exposed To Toxins In The Gulf War			
MEDICARE Claim Number			
Were You Exposed To Agent Orange			
Name Exactly As It Appears On Your MEDICARE Card			
Were You Exposed to Radiation			
15A. Veteran's Employment Status  			
| 15B. Company Name, Address, Telephone			
Date of Retirement: 			
(If employed or retired, complete 15B)			
16A. Spouse's Employment Status 			
| 16B. Company Name, Address, Telephone			
(If employed or retired, complete 16B)			
17. Does The Veteran Have Health Insurance			
|18. Does The Spouse Have Health Insurance			
    (Other Than Medicare)     			
|    (Other Than Medicare)     			
17A. Veteran's Health Insurance Co.			
|18A. Spouse's Health Insurance Co.			
17B. Name of Policy Holder  			
|18B. Name of Policy Holder   			
17C. Policy Number			
|17D. Group Code			
|18C. Policy Number			
|18D. Group Code			
19A. Name, Address and Relationship Of Next of Kin			
|19B. Home Telephone 			
|19C. Work Telephone 			
20A. Name, Adress and Relationship Of Emergency Contact			
|20B. Home Telephone 			
|20C. Work Telephone 			
21. I DESIGNATE THE FOLLOWING INDIVIDUAL TO RECEIVE POSSESSION OF ALL MY PERSONAL PROPERTY LEFT ON PREMISES UNDER VA CONTROL AFTER			
    MY DEPARTURE OR AT THE TIME OF MY DEATH. (This does not constitute a will or transfer of title.)   			
22A. Is Need For Care Due To On The Job Injury  			
|22B. Is Need For Care Due To Accident  			
SECTION II - FINANCIAL ASSESSMENT			
IIA - DEPENDENT INFORMATION			
3. Spouse's Social Security Number 			
|4. Spouse's Date Of Birth 			
|5. Child's Date Of Birth 			
|7. Child's Social Security Number			
8. Spouse's Telephone Number  			
|9. Child's Relationship To You  			
10. Date of Marriage  			
|11. Date Child Became Your Dependent  			
12. If Your Spouse or Dependent Child Did Not Live With You Last			
|13. Expenses Paid By YOUR Dependent Child for College, Vocational			
Year, Enter the Amount you Contributed To Their Support			
|Rehabilitation or Training (tuition, books, materials, etc.)			
Spouse $ 			
Child $ 			
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