English	French	Notes	Complete/Exclude
Elig. Code: 			
Amt.: $			
House Bound: 			
Tot.Ann. VA Check Amt.: $			
Amount Earned Annual Income (SPOUSE): 			
Amount of Annual Social Security (SPOUSE): 			
Type of other Annual Retirement (SPOUSE): 			
Amount of other Annual Retirement (SPOUSE): 			
Amount of other Annual Income (SPOUSE): 			
Amount of Earned Annual Income (PAYEE): 			
Amount Annual			
Soc. Sec. (PAYEE):			
Receiving Soc. Sec. (PAYEE):			
Other Annual			
Retirement (PAYEE):			
Amount Other Annual			
Income (PAYEE):			
****** HINQ Upload/edit ******			
Verification screen only			
Patient file			
BIRLS ONLY			
BIRLS/C&P			
NOT UPDATED			
HINQ Response			
** BIRLS indicates Patient is deceased.  			
** VA Monetary Ben. Terminated - Means Test Required **			
Man.ver.			
Not issued			
Pat. Type: 			
Elig. Stat.: 			
Vet. Y/N: 			
Stat. Date: 			
Disab. Ind.: 			
Elig. code: 			
WARNING: Error Indicators for 			
.. Alert found.			
Screen			
 HINQ Update . 			
 another request pending, alert cleared			
This patient data is being edited by another user			
Checking the alerts .			
. need more changes			
LOAD/EDIT Screen			
SC D			
HINQ has data not in patient file `			
Patient file has data not in HINQ `			
HINQ, Patient file are different  `			
Screen (			
Do you wish to acknowledge inconsistencies and clear this Alert ? 			
If the patient file has data that should not be updated by HINQ, this Alert			
can be acknowledged and cleared by entering 'Y'es.  Otherwise, just continue			
Press RETURN to continue,'Y'es to acknowledge, '^' to exit:			
   Alert will be cleared			
Alerts have been cleared			
3-SC Disabilities			
3+SC Disabilities			
Pension			
Disability			
5?SC Combined %			
SC LESS THAN			
2?Folder Location			
5?VA Check/Net Award			
Entering a request in the HINQ suspense file...			
Checking alert data 			
Clear corrected HINQ alerts			
Clearing corrected HINQ alerts			
No alerts cleared...			
IOINHI;IOINLOW;IOBON;IOBOFF			
Is this the patient to update (YES, NO, IGNORE, DISPLAY, ALERT)? YES//			
You are not processing an Alert, 'A'lert update and display not available.			
 'Y'es, Will continue with this patient			
 'N'o, Go next patient			
 'I'gnore, Patient will NOT appear in ALL option until reHINQ			
 'D'isplay will show you the HINQ mail message.			
 'A'lert, will update and display the Alert if processing alerts			
 '^' to quit			
* This option will print out a report, identical to the mail *			
* messages, of the patients in the suspense file with a      *			
* successful HINQ request.                                   *			
BIRLS only response and the 'Diagnostic Verified Indicator' is NO.			
Verify SC at folder location: 			
No updating allowed.			
Your version of MAS is NOT greater than 5.1, thus the Unemployable field			
is not in your patient file.  No uploading of this field allowed.			
to CONTINUE, 			
to QUIT, 			
 to update: 			
HINQ data does NOT seem right.			
Data appears to be missing for 			
Please re-HINQ for this patient.			
30 days or greater			
DVBWCHK...This init should run after PIMS v5.3 is installed			
<<PROGRAMMER NOT DEFINED>>			
*** Updating DISABILITY CONDITION file (#31)			
per VA circular 21-95-2, dated Feb. 1, 1995			
The Disability Condition file (31) update has finished.  			
 disability codes were added.			
0-DAY LETTER			
Updating '0-DAY LETTER' in the EAS MT LETTER File (#713.3)			
According to our records you have not responded to our previous requests			
to complete the financial section of VA Form 10-10EZ, Application for			
Health Benefits.  This is to inform you that your current financial			
assessment (means test) has expired.			
How Does This Affect Your Eligibility for Cost Free Care?			
  o We do not have a current means test for you on file as is required to			
    determine your eligibility for either cost-free care or reduced			
    inpatient copayments.			
How Does This Affect Your Enrollment?			
  o We are unable to determine your priority for enrollment in the VA			
    health care system.			
What Do You Need To Do?			
  o Complete, sign and return a new VA Form 10-10EZ, including the			
    financial section.			
  o Read the enclosed VA Form 4107VHA, Your Rights to Appeal our Decision.			
    If you disagree with our decision, you or your representative may			
    complete a Notice of Disagreement and return it to the Enrollment			
    Coordinator or Health Benefits Advisor at your local VA health care			
What If You Have Questions?			
DGNEW(			
NOTE: An error occurred when updating the 0-DAY LETTER			
Please contact the VistA Help Desk.			
30-DAY LETTER			
Updating '30-DAY LETTER' in the EAS MT LETTER File (#713.3)			
Each year VA requires most nonservice-connected veterans and 0% service-			
connected veterans to complete a financial assessment (means test).  Our			
records show that your annual means test is due.			
As of this date we have not received the updated financial income			
information we requested in a previous letter.			
What Does This Mean To You?			
  o An updated means test is needed to determine your ability to pay			
    copayments for your medical care and medications and your priority for			
    enrollment in the VA health care system.			
  o Failure to complete the means test by the anniversary date will cause			
    your priority for enrollment in the VA health care system to lapse.			
  o Complete and sign the enclosed Financial Assessment portion of the			
    enclosed VA Form 10-10EZ, Application for Health Benefits, reporting			
    income and assets for the previous calendar year.			
  o Return the completed and signed form in the enclosed envelope before			
    your means test anniversary date.			
  o When you report to your next health care appointment, bring your health			
    insurance card so we may update your health insurance information. 			
  o Notify us if you feel you received this letter in error.			
60-DAY LETTER			
Updating '60-DAY LETTER' in the EAS MT LETTER File (#713.3)			
  o Complete and sign the Financial Assessment portion of the enclosed VA			
    Form 10-10EZ, Application for Health Benefits, reporting income and			
    assets for the previous calendar year.			
Pre-Installation Complete, the EAS MT Letters have been updated.			
*** Updating EAS MT LETTERS file(#713.3)***			
*** Updating 0-DAY LETTER ***			
*** 0-DAY LETTER not updated ***			
*** Updating 30-DAY LETTER ***			
*** 30-DAY LETTER not updated ***			
*** Updating 60-DAY LETTER ***			
*** 60-DAY LETTER not updated ***			
Pre-scan for un-flagged 0-day letters? 			
Pre-scan will provide the number of records which will have the 0-day			
Flag-to-Print flag set to 'YES' when this routine is run in the conversion mode.			
Enter 'YES' to pre-scan, 'NO' to convert the 0-day print flags			
Beginning scan for un-flagged 0-day letters			
 records scanned			
will have			
 the 0-day flag set to print			
SITE 			
 IS NOT A DCD PILOT SITE			
POST-INSTALLATION COMPLETE			
EAS*1*20 POST-INSTALL			
EAS*1*20 POST INSTALL TASK #			
 QUEUED TO RUN 			
PATCH EAS*1*22 POST INSTALL			
EAS MT LETTERS			
Post-Install was not tasked off			
Post-Install tasked: [			
Post Install - EAS*1*22			
G.EAS MTLETTERS			
PATCH EAS-1-22			
Entries were removed from the EAS MT LETTER STATUS File (#713.2)			
which did not have a valid pointer to the EAS MT PATIENT STATUS			
File (#713.1).  The entries removed were for the processing dates			
listed below.  This is provided as information only.			
Date Processed			
Records Removed			
The following patients in the EAS MT PATIENT STATUS File (#713.1)			
do not have a corresponding entry in the EAS MT LETTER STATUS File (#713.2).			
You can try re-generating the Means Test Letter dates for these			
patients by running the REGEN procedure from the post-install			
routine by entering 'D REGEN^EAS122PT' at the programmer prompt.			
See the Patch Instructions for more details.			
Re-generate Means Test Letter Dates for patients			
identified in patch EAS*1*22 cleanup? 			
 - Patient Merge Cleanup Process			
 - PATIENT MERGE CLEANUP			
EAS*1.0*			
: PATIENT MERGE CLEANUP - PROCESS STOPPED BY USER			
: PATIENT MERGE CLEANUP - SUMMARY REPORT			
EAS MT 30 DAY LETTER PRINT			
  ** Adding a new entry to LTC CO-PAY EXEMPTION file (#714.1).			
LTC IS SERVICE RELATED - COMBAT VET ELIGIBLE			
 already exists in file #714.1.			
 not added to file #714.1			
*** Updating LTC COPAY EXEMPTION (File #714.1) ***			
  - Modifying entry #11			
    ERROR: Entry #11 not updated			
.01///LTC RELATED TO HOSPICE CARE			
  - Modifying entry #2			
    ERROR: Entry #2 not updated			
.01///INCOME (LAST YEAR) BELOW LTC THRESHOLD			
  - Adding entry #12			
INCOME (CURRENT YEAR) BELOW LTC THRESHOLD			
The Post Install will now process through PATIENT (#2) file			
to determine User Enrollee status for each Veteran by checking			
inpatient/outpatient encounter for current fiscal year, any			
future appointments and any fee basis authorizations.			
EAS*1*25			
USER ENROLLEE INITIAL DETERMINATION PROCESS			
User Enrollee initial determination process was completed in previous run.			
 is currently running User Enrollee determination			
process. Duplicate process cannot be started.			
CURRENT IEN			
by the user. Please restart the process by using the following			
command at the programmer prompt:			
Post install process for initial User Enrollee determination is completed.			
GMTII - USER ENROLLEE INITIAL DETERMINATION PROCESS			
NAIK.CHINTAN@FORUM.VA.GOV			
Site Station number: 			
Site Name: 			
Process started at           : 			
Process completed at         : 			
Total Veterans processed     : 			
Total Veterans with UE status: 			
PATIENT ADDRESS INQUIRY			
*** Address could not be determined ***			
*** No Address On File For This Patient ***			
Patient Address: 			
UNKNOWN STREET ADDRESS			
UNKNOWN CITY			
UNKNOWN STATE			
Bad Address Indicator: 			
Address Change Date: 			
Address Change Source: 			
Address Change Site: 			
LEGALLY SEPARATED			
EXPENSE(408.21,			
Answer Yes or No where applicable (Otherwise provide the requested information)			
3. Are You Eligible for Medicaid?			
|3A. Are You Enrolled in Medicare Part A (Hospital Insurance)			
|3B. Effective Date (If 			
4. Are You Enrolled in Medicare Part B (Medical Insurance)			
|4A. Effective Date (If 			
|4B. Medicare Claim Number			
SECTION II - INSURANCE INFORMATION			
5. Are You Covered By Health Insurance (including coverage through a spouse)? (If 			
, provide the following information for			
all insurance company(s) providing coverage to you.)			
. Name of Insurance Company			
A. Address of Insurance Company			
B. Phone Number of Insurance Company			
C. Name of Policy Holder			
D. Relationship of Policy Holder			
E. Policy Number			
F. Group Name and/or Number			
SECTION III - SPOUSE/DEPENDENT INFORMATION			
9. Current Marital Status			
9B. Spouse Residing in the Community?			
|9C. Spouse's Social Security Number			
9A. Spouse Residing in the Community?			
|9B. Spouse's Social Security Number			
A. Dependent's Date of Birth			
B. Dependent's Social Security Number			
C. Dependent Residing in the Community?			
We need to collect information regarding income, assets, and 			
expenses for you and your spouse.  If you do not wish to provide this			
information you must sign agreeing to make copayments and will 			
be charged the maximum copayment amount for all services.  See the			
top of page 2, read, sign, and date.			
I do not wish to provide my detailed financial information.  			
I understand that I will be assessed the maximum copayment amount for			
extended care services and agree to pay the applicable VA copayment as required by law.			
Signature			
SECTION IV - FIXED ASSETS (VETERAN AND SPOUSE)			
1. Residence (Market value minus any outstanding mortgage or 			
lien - exclude if veteran			
receiving only non-institutional services or spouse or 			
dependent residing in community).			
2. Other Residences/Land/Farm or Ranch (Market value minus any 			
outstanding mortgage or lien)			
3. Vehicle(s)* (Value minus any outstanding lien - exclude if veteran is 			
receiving only			
non-institutional services or spouse or dependent residing in community).			
| SUBTOTAL (Sum of lines 1 through 3)			
SECTION V - LIQUID ASSETS (VETERAN AND SPOUSE)			
1. Cash, e.g., interest, dividends from IRA, 401K's and other 			
tax deferred annuities 			
(including checking, savings, money market, etc.)			
2. Stocks, bonds, mutual funds, SEP's, and other retirement 			
annuities, self-employed person)			
3. Other Liquid Assets (Includes such items as stamp or coin 			
collections, art work, collectibles			
household furniture and other household goods, clothing, jewelry, and 			
personal items			
minus amount owed).			
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