English	French	Notes	Complete/Exclude
Do you wish to return to Screen #9 to enter missing Income Data? 			
A means test for this encounter date was not found and may be required!			
Further investigation will be needed.			
Press ENTER to continue 			
Patient Requires a means Test			
Primary Means Test Required from '			
SCENI MEANS TEST EDIT			
You do not have the appropriate IEMM Security Key.  Contact your supervisor.			
Do you wish to proceed with the means test at this time			
No registrations to print from.			
Registration date/time: 			
Enter the date and time, Entry #, or 'L' for the last registration,			
 to select the registration you wish to print a 10/10 for.			
This output requires 132 column output to a PRINTER.			
Output to SCREEN will be unreadable.			
FACILITY NOT IDENTIFIED			
APPLICATION FOR MEDICAL BENEFITS			
PRINT 			
ENTER 'Y'ES TO PRINT A 			
.  OTHERWISE ENTER 'N'O.			
NOT APPLICABLE			
SEE ATTACHMENT FOR PAPERWORK REDUCTION INFORMATION AND PRIVACY ACT INFORMATION			
PART I - PATIENT DATA			
1.  Type of benefit applied for:  			
HOSPITAL/OUTPATIENT TREATMENT^DOMICILIARY CARE^HOSPITAL/OUTPATIENT TREATMENT^OUTPATIENT DENTAL^NURSING HOME CARE			
 3.  Other names used (Alias)			
 4.  Social Security Number			
5.   Claim Number			
| 6.  LOCATION OF CLAIMS FOLDER			
| 7.  DATE OF BIRTH			
| 8.  PLACE OF BIRTH			
9.   PERMANENT ADDRESS			
 10.  TEMPORARY ADDRESS 			
9A.  STREET ADDRESS:			
 10A. STREET ADDRESS:			
9D.  ZIP CODE: 			
10D. ZIP CODE: 			
9F.  HOME TELEPHONE NUMBER: 			
10F. HOME TELEPHONE NUMBER:			
11. CONFIDENTIAL ADDRESS			
Not Applicable			
11A.  STREET ADDRESS:			
11D.  ZIP CODE:  			
| 11F. START DATE: 			
| STOP DATE: 			
11G. Active Confidential Address Categories			
13.  MOTHER'S MAIDEN NAME			
16.  RELIGIOUS PREFERENCE			
17.  DATE OF PREVIOUS CARE			
18.  LOCATION OF PREVIOUS CARE			
19.  SPINAL CORD INJURY			
PARAPLEGIA-TRAUMATIC			
QUADRIPLEGIA-TRAUMATIC			
PARAPLEGIA-NONTRAUMATIC			
QUADRIPLEGIA-NONTRAUMATIC			
PART II - EMERGENCY CONTACT DATA			
1A.  FIRST NEXT OF KIN			
2A.  SECOND NEXT OF KIN			
3A.  FIRST CONTACT IN AN EMERGENCY			
4A.  SECOND CONTACT IN AN EMERGENCY			
C.  HOME TELEPHONE NUMBER			
D.  WORK TELEPHONE NUMBER			
E.  ADDRESS (Number, Street, City, State, ZIP Code)			
Reg Date/Time:  			
PRINTED: 			
Clerk: 			
AUTOMATED VA FORM 10-10			
PART III - APPLICANT/SPOUSE DATA			
1.   APPLICANT'S EMPLOYMENT STATUS: 			
2.   SPOUSE'S EMPLOYMENT STATUS:  			
3. APPLICANT INFORMATION			
3B.  EMPLOYER (Name, Street Address, City, State, Zip)			
4B.  EMPLOYER (Name, Street Address, City, State, Zip)			
3C.  WORK TELEPHONE NUMBER: 			
4C.  WORK TELEPHONE NUMBER: 			
NOT ANSWERED			
PART IV - MILITARY SERVICE DATA			
1A. LAST BRANCH OF SERVICE			
1B. LAST SERVICE NUMBER			
1C. LAST DATE OF ENTRY			
1D. LAST DISCHARGE DATE			
1E. DISCHARGE TYPE			
2A. PRIOR BRANCH OF SERVICE			
2B. PRIOR SERVICE NUMBER			
2C. PRIOR DATE OF ENTRY			
2D. PRIOR DISCHARGE DATE			
2E. DISCHARGE TYPE			
3A. PRIOR BRANCH OF SERVICE			
3B. PRIOR SERVICE NUMBER			
3C. PRIOR DATE OF ENTRY			
3D. PRIOR DISCHARGE DATE			
3E. DISCHARGE TYPE			
PART V - ELIGIBILITY STATUS DATA			
1.  PATIENT TYPE: 			
2.  IS NEED FOR MEDICAL CARE RELATED TO AN			
3.  IS THE NEED FOR MEDICAL CARE RELATED			
4.  IS PATIENT ELIGIBLE FOR MEDICAID:			
    ON THE JOB INJURY: 			
TO AN ACCIDENT: 			
5A. DOES PATIENT HAVE HEALTH INSURANCE			
5B. IF YES, COVERAGE PROVIDED BY:			
COVERAGE: 			
PATIENT'S INSURANCE			
SPOUSE'S INSURANCE			
NO ACTIVE (UNEXPIRED) INSURANCE ON FILE FOR THIS APPLICANT			
6.  DOES VETERAN HAVE GI			
7. PRIMARY ELIGIBILITY CODE			
8. OTHER ELIGIBILITY CODE			
9. PERIOD OF SERVICE			
INSURANCE: 			
10. SERVICE CONNECTED CONDITIONS AS STATED BY APPLICANT:			
10. RATED SERVICE CONNECTED CONDITIONS: 			
NO RATED SERVICE-CONNECTED CONDITIONS			
10. SERVICE CONNECTED CONDITIONS: 			
NOT APPLICABLE: NOT A SERVICE-CONNECTED APPLICANT			
PART VI - INCOME SCREENING DATA OR ANNUAL INCOME			
1A.  CURRENT MARITAL STATUS: 			
1B.  DATE OF MARRIAGE: 			
2A. WAS PATIENT MARRIED OR SEPARATED AT THE END OF LAST CALENDAR YEAR?: 			
2B. NAME OF SPOUSE			
2C. SEX OF SPOUSE			
2D. SPOUSE'S SOCIAL SECURITY NO			
2E. SPOUSE'S DATE OF BIRTH			
B. SOCIAL SECURITY NO			
D. DATE OF BIRTH			
F. DEPENDENT AS			
NONE INDICATED			
4.  PREVIOUS CALENDAR YEAR (			
) INCOME INFORMATION			
CHECK ALL APPLICABLE BOXES			
11.  TOTAL INCOME			
PART VII - INELIGIBLE/MISSING DATA			
1.   INELIGIBLE DATE			
2.   TWX SOURCE			
3.   TWX CITY			
4.   TWX STATE			
6.   VACO DECISION: 			
7.   MISSING DATE			
8.   TWX SOURCE			
9.   TWX CITY			
10.  TWX STATE			
1.  ELIGIBILITY STATUS			
2.  STATUS DATE			
3.  STATUS ENTERED BY			
PENDING VERIFICATION			
RE-VERIFY			
4.  VERIFICATION METHOD			
5.  SERVICE VERIFICATION DATE			
6.  RATED DISABILITIES			
SIGNATURE OF APPLICANT OR APPLICANT'S REPRESENTATIVE			
FOR VA USE ONLY			
VA FACILITY NUMBER			
ADMISSION DATE			
AUTHORITY FOR ADMISSION OR TREATMENT			
SUPPLEMENTAL DATA SHEET			
HEALTH SUMMARY			
DRUG PROFILE			
ENCOUNTER FORMS			
No Type Selected.  HS will not print			
Select type of Drug Profile			
11. OTHER ELIGIBILITY DATA			
L. SERVICE IN PERSIAN GULF THEATER			
B. PRISONER OF WAR STATUS			
M. DENTAL INJ. |			
   TEETH EXTRACTED			
C. EXPOSURE TO AGENT ORANGE			
N. SERVICE CONNECTED			
D. EXPOSURE TO RADIATION			
O. RECEIVING AID & ATTENDANCE			
E. COMBAT SERVICE			
P. RECEIVING HOUSEBOUND			
F. MILITARY DISABILITY			
Q. RECEIVING VA PENSION			
G. VIETNAM SERVICE			
R. RECEIVING VA DISABILITY			
H. LEBANON SERVICE			
S. SERVICE IN SOMALIA			
I. GRENADA SERVICE			
T. SERVICE IN YUGOSLAVIA			
J. PANAMA SERVICE			
U. PURPLE HEART RECIPIENT			
K. PERSIAN GULF SERVICE			
V. VA MONETARY AMOUNT:			
3.  Other Name(s):  			
NO ALIAS' ON FILE			
NO REMARKS CURRENTLY ENTERED FOR THIS APPLICANT			
5.  Fathers Name:  			
NOT SPECIFIED			
Mothers Name:  			
Mothers Maiden Name:  			
6a. Enrollment Clinic(s):  			
NOT ACTIVELY ENROLLED IN ANY CLINICS AT THIS TIME			
6b. Future Appointments:  			
NO PENDING APPOINTMENTS ON FILE			
7a. Last Admission:  			
NO PREVIOUS ADMISSIONS TO THIS FACILITY ON FILE			
LAST ADMISSION PTF DATA NO LONGER STORED			
7b. Discharge Diagnosis(es):  			
NO DIAGNOSES ON FILE FOR THIS ADMISSION PERIOD YET			
7c. Admit Diagnosis:  			
7d. Diagnosis Responsible for Greatest Length of Stay:  			
8.  Eligibility Status:  			
PENDING RE-VERIFICATION			
UNKNOWN OR NONE			
| Status Date:  			
Verification Method:  			
ELIGIBLE APPLICANT -- NOT APPLICABLE			
Ineligible Date:  			
CITY UNKNOWN			
STATE UNKNOWN			
VARO DECISION UNKNOWN			
| TWX Source:  			
TWX City:  			
| TWX State:  			
VARO Decision:  			
9.  Vietnam Service:  			
From:  			
To    :  			
Agent Orange:  			
Reg :  			
Exam  :  			
Reg #:  			
Loc:  			
ION Radiation:  			
Method:  			
Prisoner of War:  			
Where:  			
Combat:  			
Purple Heart:  			
Status:  			
Remarks:  			
10. Next of Kin, Address and Zip Code:			
Name:  			
KOREAN DMZ			
NAGASAKI/HIROSHIMA			
NUCLEAR TESTING			
NUCLEAR TESTING & NAGASAKI/HIROSHIMA			
STREET ADDRESS UNKNOWN			
CITY STATE UNKNOWN			
GLOBAL SUBSCRIPT LOCATION			
Unknown/Invalid pointer, DD(			
GLOBAL NAME			
Cannot convert the 			
 in the 			
        File 11 and 13 Conversion Problem list			
MARITAL STATUS (#11) File Conversion Problems:			
RELIGION (#13) File Converion Problems:			
No problems			
Pointer File/Subfile^Field^Problem Description			
DG*5.3*172			
DGY(			
File 11 and 13 Conversion Problems			
*** Conversion is not necessary! ***			
Uninstalling patch...			
*** Not all non-standard entries have been mapped...see DG172 options ***			
*** Job appears to already be running! ***			
Are you sure you want to start the conversion process			
Marital/Religion File Conversion			
Are you sure you want to stop the background conversion process			
*** Job will stop soon ***			
*** Conversion process is NOT running! ***			
RGPR PRE-IMP MENU			
DG172 			
RELIGION/MARITAL STATUS REINDEX			
Reindex Religion and Marital Status file xrefs ...			
Setting up files that need to be converted...			
Setting up standard/non-standard mapping file...			
You can not re-start this process!			
*** No mapping necessary! ***			
Select Non-Standard 			
Marital Status: 			
Religion: 			
Religion/Marital Status Conversion			
Conversion Finished			
DG172(1,			
Conversion *NOT* Finished			
The conversion process appears to have been stopped.			
To finish the conversion process, restart by using			
the 'Begin Religion/Marital Status Conversion' option			
on the CIRN Pre-Implementation Menu.			
Marital Status			
Religion			
 File Non-Standard Entries:			
All non-standard entries listed above have been removed			
from their respective files.			
Entry: 			
 repointed to: 			
 Starting post-install process...			
 Post-install process has completed.			
 total records have been identified and corrected.			
Report cancelled!			
Means Test Update Report			
Updated Means Test Listing			
Run Date: 			
Veteran Name			
Veteran SSN			
Year			
Old Status			
New Status			
Income Year			
Old Means Test Status			
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