English French Notes Complete/Exclude Y - If you want to purge data. N - If you don't wish to purge data. Purge patients not seen since: SELECT A DATE IN THE PAST PLEASE!! I'm going to purge all patients from the INCONSISTENT DATA file who haven't been admitted or registered since Is this correct Y - To start the purge process. N - To QUIT. Generate a listing of inconsistent data elements by: CHOOSE OUTPUT METHOD OR ENTER '^' TO QUIT: The available choices are: Go To List by (N)ame or (T)erminal Digit: N - To generate listing in Alphabetical Order T - To generate listing in Terminal Digit Order. THIS OUTPUT REQUIRES 132 COLUMN OUTPUT INCONSISTENT ELEMENTS FOR PATIENTS WITH A Missing Last Day Home Phone # Soc Sec # ID'ed Edited by Inconsistent/Missing Data Elements TABLE OF INCONSISTENT/MISSING DATA ELEMENTS UNIDENTIFIED PATIENT # Do you want to delete the existing entries and rebuild the file Y - If you want to remove all existing entries from the INCONSISTENT DATA file and rebuild from scratch. N - If you just want to add newly identified inconsistencies to the existing file. Rebuild for patients seen since what date: I'm going to check all patients who were admitted or registered on or after [Within the Past DELETE all existing entries prior to rebuilding add any new inconsistent data elements to the existing file Y - If this is what you want to do. N - If you wish to STOP processing and reconsider this action. INCONSISTENT DATA^38.5P^^0 ' OPTION RUNNING FROM UNABLE TO RUN THIS OPTION AT CURRENT TIME!! Do you really want to update existing inconsistent entries Y - If you want me to run through all the entries currently filed in the INCONSISTENT DATA file and verify they're still inconsistent. N - If you wish to QUIT and rethink this action. This check can not be edited. It is automatically turned Temporary: POS: Claim #: Relig: Ethnicity: Primary Eligibility: PENDING REVERIFICATION Other Eligibilities: Confidential Address: From/To: NOT APPLICABLE From/To: COORDINATING MASTER OF RECORD: Scheduled Admit for treating specialty Currently enrolled in Future Appointments: See Scheduling options for additional appointments. * NO ACTION TAKEN * Press RETURN to CONTINUE: Catastrophically Disabled Review Date: Primary Elig. Code: Other Elig. Code(s): Service Connected: NO SC Percent: NOT A VETERAN Health Insurance: Medicaid Elig: Means Test Status: NOT IN MEANS TEST FILE Invalid pseudo SSN. Type 'P' for the valid one Pseudo SSN adjusted to match edited name value ==> VERIFY FIELDS Already used by patient ' The SSN must not begin with 9. First three digits cannot be zeros. Note: This is a RR Retirement SSN. Note: This is a Test Patient SSN. Collateral of Must have same SSN to be collateral Has collateral be sure to change SSN The date of birth is too early for the selected category of beneficiary Make another selection or correct the date of birth. The date of birth is too late for the selected category of beneficiary. The patient's age is too young for the selected category of beneficiary. This service entry date would make the patient too young for service. DOB Previous service entry date is not on file This service entry date must be before than the first service entry date This service entry date must be less than the second service entry date The service separation date must be after the entry date This service separation date must be before the next service entry date The service separation date must be before the next service entry date **NOTE-Change(s) made in this session deleted the veteran's Combat Vet status! But I need a Start Date for this Temporary Address. But I need at least one line of a Temporary address. But I need a Start Date. But I need at least one active category. I need at least one line of Address. But I need to know where you were treated most recently. Patient is not a veteran. Can't enter rated disabilities SPOUSE'S DEPENDENT'S CHILD'S Incomplete Entry...Deleted No dependents to inactivate! Enter a number 1- to indicate the dependent you wish to inactivate: indicating the number of the dependent you wish to inactivate RELATIONSHIP: Entry incomplete...deleted Dependent has been inactivated as of Date no longer a dependent Enter the date this person was no longer a dependent of the veteran. This could include a date of death or the date a child turned 18 for children. For a spouse, this would be the date of divorce or date of death of the spouse. Date must be after the person became a dependent, but prior to 12/31/ A person should only be inactivated if the individual was not a dependent at any time during the prior calendar year. A spouse should be inactivated if the spouse and veteran were not married as of 12/31/ Warning: Data will be used if dependent was active at least one day in a year. Data will not be used if inactivation is prior to 1/1/ or it is equal to the activation date. Do you wish to inactivate this dependent on the selected date? [Must edit through means test!!] EFFECTIVE DATE Please return to screen 8 and check the veteran's effective date. The effective date was created based on the veteran's date of birth. You might also want to check the date of birth for this veteran. This dependent is 18 years or older. To list this person as a dependent they have to be: 1. An UNMARRIED child who is under the age of 18. 2. Between the ages of 18 and 23 and attending school. 3. An unmarried child over the age of 17 who became permanently incapable of self support before the age of 18. Use 'Expand Dependent' option to change effective date. Enter the date this person first became a dependent of the veteran. In the case of a spouse, this would be the date of marriage. For a parent or other dependent, this would be the date the dependent moved in. For a child, this would be the date of birth or date of Date must be before DEC 31, as dependents are collected for the prior calendar year only. Enter '^' to stop the display and edit of data, '^N' to jump to screen #N (see listing below), to continue on to the next available screen or enter the field group number(s) you wish to edit using commas and dashes as delimiters. Those groups enclosed in brackets are editable while those enclosed in arrows are not. Enter 'ALL' to edit all editable data elements on the screen. You may precede your selection with 'V' to denote veteran. DATA GROUPS ON SCREEN Press RETURN key to EXIT Screen TO EXIT Name, SSN, DOB^Alias Name & SSN (if applicable)^Remarks concerning this patient^Home Address, Phone & Work Phone^Temporary Address, Dates, Phone Confidential Address,Dates and Types Sex, POB, Parents, etc.^Dates/Locations of Previous Care^Race and Ethnicity Primary Next-of-Kin^Secondary Next-of-Kin^Primary Emergency Contact^Secondary Emergency Contact^Designee to receive personal effects Applicant Employer, Address^Spouses Employer, Address Unexpired Insurance Policies^Eligibile for Medicaid Service History^Prisoner of War^Combat^Vietnam Service^Agent Orange Exposure^IONizing Radiation Exposure^ Lebanon Service^Grenada Service^Panama Service^Persian Gulf Service^Somalia Service^Environmental Contaminants Exposure^Military Retirement/Disability^Dental History^Yugoslavia Service^Purple Heart Recipient^ Nose/Throat Radium Treatment Patient Type, SC Data, Claim Info^VA Monetary Benefits^POS, Eligibility Code(s)^SC Conditions relayed by applicant Spouse's Demographic Info^Dependents' Demographic Info Social Security^U.S. Civil Service^U.S. Railroad Retirement^Military Retirement^Unemployment^Other Retirement^Total Employment Income^Interest,Dividend,Annuity^Workers Comp or Black Lung^Other Income Ineligible Patient Information^Missing Patient Information Eligibility Verification^Monetary Benefits Verification^Service Record Verification^Rated Disabilities (VA) Four most recent admission episodes on file for this applicant are displayed in inverse order. Four most recent applications for care (registrations) are displayed in inverse order. Clinics in which actively enrolled^Pending (future) appointments Sponsor information is displayed for patients. Demographic^Confidential Address^Patient^Contact^Employment^Insurance^Service Record^Eligibility^Family Demographic^Income Screening^Missing/Ineligible^Eligibility Verification^ Admission Info^Application Info^Appointment Info^Sponsor Demograhics Enter your division: Unable to update Purple Heart Data. Unable to update Purple Heart History. =ENTER new to EDIT, for screen N or to QUIT COPYING will move Family Demographic and Income Data into the next year... YOU HAVE ALREADY MODIFIED CURRENT YEAR DEPENDENT INFORMATION COPYING will OVERWRITE this modified dependent information with LAST year's data - ** Please review dependent data ** ...FAMILY DEMOGRAPHIC DATA COPIED ...............INCOME DATA COPIED ===> Record has been classified as sensitive. Your MAS PARAMETER file is not properly set up! LOCAL REGISTRATION QUESTIONS INVALID SCREEN NUMBER...VALID SCREENS ARE (To edit only veteran income, precede selection with 'V' [ex. 'V1-3'] precede with 'S' to edit spouse precede with 'D' to edit dependents >>> Patient cannot be registered while there is still an open disposition. Patient: Eligibility, Demographic Emergency Contact and Military Service Marital Another user is editing, try later... Insurance HINQ Inquiry Consistency Checker At this time you may Register the patient if he or she is present and seeking care. Answer 'No' if this was a mail-in application. Would you like to Register the patient Exit Interview PRINT 10/10T DGRPT 10-10T REGISTRATION Patient Demographics Permanent Address: Emergency Contact NOK: Military Service Service Branch [Last]: Number [Last]: Purple Heart: Eligibility Patient Type: Primary Elig Code: Marital/Spouse Spouse's Name: Last Year's Estimated Covered by Health Insurance: Insurance Co. Subscriber ID Group Holder Effective Expires PRINT 10-10T - FROM REGISTRATION Reg Date/Time: AUTOMATED VA FORM 10-10T VA FORM 10-10T |2. Social Security Number |3. Date of Birth 4A. Applicant's Mailing Street Address |4D. Zip Code |6. Home Telephone Number |7. Work Telephone Number 8A. Emergency Contact |8C. Home Telephone Number |8D. Work Telephone Number 8E. Mailing Address of Emergency Contact |9. Is Emergency Contact |Also Next of Kin 10. Benefit Applying For: HOSPITAL/OUTPATIENT TREATMENT 11. Applicant Status: A. Service Connected |B. Prisoner of War |C. Aid and Attendance |D. Military Disability Retired E. VA Pension |F. Primary Eligibility Code |G. Other Eligibility Code |H. Purple Heart Recipient 12. Exposure To: |A. Agent Orange |C. Environmental Contaminants 13. Medical Care Related To: 14A. Do You Have Health Coverage |14B. Name of Health Insurance Carrier 15. Branch of Service |16. Latest Service Number |17. Marital Status |18B. Spouse's Social Security Number 18C. Year of Marriage |18D. Number of Dependents |19. Last Year's Estimated Taxable Income Consent To Release Information: I hereby authorize the Department of Veterans Affairs to disclose any such history, diagnostic and treatment information from my medical records (including information relating to the diagnosis, treatment or other therapy for the conditions of drug abuse, alcoholism or alcohol abuse, sickle cell anemia, or testing for or infection with the human immunodeficiency virus) to the carrier or contractor of any health plan contract under which I am apparently entitled to medical care or payment of the expense of care that is identified above, as considered necessary by VA representatives for the discharge of the legal or contractual obligations of the insurer or 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. Co-payment Notice: If your household income exceeds the established threshold, you will be considered Discretionary Such veterans must pay a co-payment not to exceed the Medicare deductible, plus a per diem for hospital and nursing care. By signing this application, you are agreeing to pay the VA the applicable co-payment if you are determined to be a Signature of Applicant Public reporting burden for this collection of information is estimated to average 10 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the #################### #################### #################### #################### #################### #################### #################### #################### #################### #################### #################### #################### #################### #################### ####################