EASEC101 ;ALB/BRM,LBD - Print 1010EC LTC Enrollment Form ; 9/6/01 9:46am
;;1.0;ENROLLMENT APPLICATION SYSTEM;**5,40**;Mar 15, 2001
;
; Called from ^EASEC10E to print page 1 of the 1010EC
;
PAGE1(EALNE,EAINFO,EASDFN) ;Print page 1
N X,EASROOT
S EASROOT="^TMP(""1010EC"",$J,"_EASDFN_","
D HDRMAIN^EASEC10E(.EALNE)
D SEC1
D SEC2
D SEC3
D DISCLAIM
D FT^EASEC10E(.EALNE,.EAINFO)
Q
SEC1 ;print section 1 - General Information
N EAS1
S EAS1=EASROOT_"1)"
W !,"1. Veteran's Name",?100,"|2. Social Security Number"
W !?3,@EAS1@(1),?100,"|",?104,@EAS1@(2),?131,$C(13) X EAINFO("L")
;
W !?26,"Answer Yes or No where applicable (Otherwise provide the requested information)",?131,$C(13) X EAINFO("L")
;
W !,"3. Are You Eligible for Medicaid?"
W ?36,"|3A. Are You Enrolled in Medicare Part A (Hospital Insurance)"
W ?100,"|3B. Effective Date (If ""Yes"")"
W !?3,@EAS1@(3),?36,"|",?41,@EAS1@(4),?100,"|",?105,@EAS1@(5),?131,$C(13) X EAINFO("L")
;
W !,"4. Are You Enrolled in Medicare Part B (Medical Insurance)"
W ?63,"|4A. Effective Date (If ""Yes"")"
W ?97,"|4B. Medicare Claim Number"
W !?3,@EAS1@(6),?63,"|",?68,@EAS1@(7),?97,"|",?102,@EAS1@(8),?131,$C(13) X EAINFO("L")
Q
SEC2 ;print section 2 - Insurance Information
N EAS2,X
S EAS2=EASROOT_"2)"
;
W !?48,"SECTION II - INSURANCE INFORMATION",!,EALNE("D")
;
W !,"5. Are You Covered By Health Insurance (including coverage through a spouse)? (If ""Yes"", provide the following information for"
W !?3,"all insurance company(s) providing coverage to you.)"
W !?3,@EAS2@(1),?131,$C(13) X EAINFO("L")
;
F X=2,9,16 D ;loop through insurance companies
.W !,$S(X=2:6,X=9:7,X=16:8)_". Name of Insurance Company"
.W ?40,"|"_$S(X=2:6,X=9:7,X=16:8)_"A. Address of Insurance Company"
.W ?90,"|"_$S(X=2:6,X=9:7,X=16:8)_"B. Phone Number of Insurance Company"
.W !?3,@EAS2@(X),?40,"|",?45,@EAS2@(X+1,.111),?90,"|",?95,@EAS2@(X+2),?131,$C(13)
.W:$G(@EAS2@(X+1,.112))'="" !?40,"|",?45,@EAS2@(X+1,.112),?90,"|",?131,$C(13)
.W:$G(@EAS2@(X+1,.113))'="" !?40,"|",?45,@EAS2@(X+1,.113),?90,"|",?131,$C(13)
.W !?40,"|",?45,@EAS2@(X+1,.114) W:@EAS2@(X+1,.114)]"" ","
.W @EAS2@(X+1,.115)," ",@EAS2@(X+1,.116),?90,"|",?131,$C(13) X EAINFO("L")
.;
.W !,$S(X=2:6,X=9:7,X=16:8)_"C. Name of Policy Holder"
.W ?40,"|"_$S(X=2:6,X=9:7,X=16:8)_"D. Relationship of Policy Holder"
.W ?75,"|"_$S(X=2:6,X=9:7,X=16:8)_"E. Policy Number"
.W ?100,"|"_$S(X=2:6,X=9:7,X=16:8)_"F. Group Name and/or Number"
.W !?4,@EAS2@(X+3),?40,"|",?45,@EAS2@(X+4),?75,"|"
.W ?80,@EAS2@(X+5),?100,"|",?105,@EAS2@(X+6),$C(13) X EAINFO("L")
Q
SEC3 ;print section 3 - Spouse/Dependent Information
;This section was modified to print Current Marital Status for the
;new 10-10EC form. Added for LTC Phase IV (EAS*1*40)
N X,EAS3
S EAS3=EASROOT_"3)"
W !?44,"SECTION III - SPOUSE/DEPENDENT INFORMATION",!,EALNE("D")
;
I $G(EAINFO("FORM")) D
.W !,"9. Current Marital Status"
.W ?55,"|9A. Spouse's Name (Last, First, MI)"
.W !?3,@EAS3@(0),?55,"|",?61,@EAS3@(1),?131,$C(13) X EAINFO("L")
.;
.W !,"9B. Spouse Residing in the Community?"
.W ?90,"|9C. Spouse's Social Security Number"
.W !?4,@EAS3@(2),?90,"|",?95,@EAS3@(3),?131,$C(13) X EAINFO("L")
;
I '$G(EAINFO("FORM")) D
.W !,"9. Spouse's Name (Last,First,MI)"
.W !?3,@EAS3@(1),?131,$C(13) X EAINFO("L")
.;
.W !,"9A. Spouse Residing in the Community?"
.W ?90,"|9B. Spouse's Social Security Number"
.W !?4,@EAS3@(2),?90,"|",?95,@EAS3@(3),?131,$C(13) X EAINFO("L")
;
F X=4,8 D ;loop through dependents
.W !,$S(X=4:10,X=8:11)_". Dependent's Name (Last, First, MI)"
.W ?55,"|",$S(X=4:10,X=8:11)_"A. Dependent's Date of Birth"
.W ?90,"|",$S(X=4:10,X=8:11)_"B. Dependent's Social Security Number"
.W !?4,@EAS3@(X),?55,"|",?61,@EAS3@(X+1),?90,"|",?96,@EAS3@(X+2),?131,$C(13) X EAINFO("L")
.;
.W !,$S(X=4:10,X=8:11)_"C. Dependent Residing in the Community?"
.W !?5,@EAS3@(X+3),?131,$C(13) X EAINFO("L")
Q
DISCLAIM ;
W !,"We need to collect information regarding income, assets, and "
W "expenses for you and your spouse. If you do not wish to provide this"
W !,"information you must sign agreeing to make copayments and will "
W "be charged the maximum copayment amount for all services. See the"
W !,"top of page 2, read, sign, and date."
Q
--- Routine Detail --- with STRUCTURED ROUTINE LISTING ---[H[J[2J[HEASEC101 4352 printed Sep 23, 2025@19:29:48 Page 2
EASEC101 ;ALB/BRM,LBD - Print 1010EC LTC Enrollment Form ; 9/6/01 9:46am
+1 ;;1.0;ENROLLMENT APPLICATION SYSTEM;**5,40**;Mar 15, 2001
+2 ;
+3 ; Called from ^EASEC10E to print page 1 of the 1010EC
+4 ;
PAGE1(EALNE,EAINFO,EASDFN) ;Print page 1
+1 NEW X,EASROOT
+2 SET EASROOT="^TMP(""1010EC"",$J,"_EASDFN_","
+3 DO HDRMAIN^EASEC10E(.EALNE)
+4 DO SEC1
+5 DO SEC2
+6 DO SEC3
+7 DO DISCLAIM
+8 DO FT^EASEC10E(.EALNE,.EAINFO)
+9 QUIT
SEC1 ;print section 1 - General Information
+1 NEW EAS1
+2 SET EAS1=EASROOT_"1)"
+3 WRITE !,"1. Veteran's Name",?100,"|2. Social Security Number"
+4 WRITE !?3,@EAS1@(1),?100,"|",?104,@EAS1@(2),?131,$CHAR(13)
XECUTE EAINFO("L")
+5 ;
+6 WRITE !?26,"Answer Yes or No where applicable (Otherwise provide the requested information)",?131,$CHAR(13)
XECUTE EAINFO("L")
+7 ;
+8 WRITE !,"3. Are You Eligible for Medicaid?"
+9 WRITE ?36,"|3A. Are You Enrolled in Medicare Part A (Hospital Insurance)"
+10 WRITE ?100,"|3B. Effective Date (If ""Yes"")"
+11 WRITE !?3,@EAS1@(3),?36,"|",?41,@EAS1@(4),?100,"|",?105,@EAS1@(5),?131,$CHAR(13)
XECUTE EAINFO("L")
+12 ;
+13 WRITE !,"4. Are You Enrolled in Medicare Part B (Medical Insurance)"
+14 WRITE ?63,"|4A. Effective Date (If ""Yes"")"
+15 WRITE ?97,"|4B. Medicare Claim Number"
+16 WRITE !?3,@EAS1@(6),?63,"|",?68,@EAS1@(7),?97,"|",?102,@EAS1@(8),?131,$CHAR(13)
XECUTE EAINFO("L")
+17 QUIT
SEC2 ;print section 2 - Insurance Information
+1 NEW EAS2,X
+2 SET EAS2=EASROOT_"2)"
+3 ;
+4 WRITE !?48,"SECTION II - INSURANCE INFORMATION",!,EALNE("D")
+5 ;
+6 WRITE !,"5. Are You Covered By Health Insurance (including coverage through a spouse)? (If ""Yes"", provide the following information for"
+7 WRITE !?3,"all insurance company(s) providing coverage to you.)"
+8 WRITE !?3,@EAS2@(1),?131,$CHAR(13)
XECUTE EAINFO("L")
+9 ;
+10 ;loop through insurance companies
FOR X=2,9,16
Begin DoDot:1
+11 WRITE !,$SELECT(X=2:6,X=9:7,X=16:8)_". Name of Insurance Company"
+12 WRITE ?40,"|"_$SELECT(X=2:6,X=9:7,X=16:8)_"A. Address of Insurance Company"
+13 WRITE ?90,"|"_$SELECT(X=2:6,X=9:7,X=16:8)_"B. Phone Number of Insurance Company"
+14 WRITE !?3,@EAS2@(X),?40,"|",?45,@EAS2@(X+1,.111),?90,"|",?95,@EAS2@(X+2),?131,$CHAR(13)
+15 if $GET(@EAS2@(X+1,.112))'=""
WRITE !?40,"|",?45,@EAS2@(X+1,.112),?90,"|",?131,$CHAR(13)
+16 if $GET(@EAS2@(X+1,.113))'=""
WRITE !?40,"|",?45,@EAS2@(X+1,.113),?90,"|",?131,$CHAR(13)
+17 WRITE !?40,"|",?45,@EAS2@(X+1,.114)
if @EAS2@(X+1,.114)]""
WRITE ","
+18 WRITE @EAS2@(X+1,.115)," ",@EAS2@(X+1,.116),?90,"|",?131,$CHAR(13)
XECUTE EAINFO("L")
+19 ;
+20 WRITE !,$SELECT(X=2:6,X=9:7,X=16:8)_"C. Name of Policy Holder"
+21 WRITE ?40,"|"_$SELECT(X=2:6,X=9:7,X=16:8)_"D. Relationship of Policy Holder"
+22 WRITE ?75,"|"_$SELECT(X=2:6,X=9:7,X=16:8)_"E. Policy Number"
+23 WRITE ?100,"|"_$SELECT(X=2:6,X=9:7,X=16:8)_"F. Group Name and/or Number"
+24 WRITE !?4,@EAS2@(X+3),?40,"|",?45,@EAS2@(X+4),?75,"|"
+25 WRITE ?80,@EAS2@(X+5),?100,"|",?105,@EAS2@(X+6),$CHAR(13)
XECUTE EAINFO("L")
End DoDot:1
+26 QUIT
SEC3 ;print section 3 - Spouse/Dependent Information
+1 ;This section was modified to print Current Marital Status for the
+2 ;new 10-10EC form. Added for LTC Phase IV (EAS*1*40)
+3 NEW X,EAS3
+4 SET EAS3=EASROOT_"3)"
+5 WRITE !?44,"SECTION III - SPOUSE/DEPENDENT INFORMATION",!,EALNE("D")
+6 ;
+7 IF $GET(EAINFO("FORM"))
Begin DoDot:1
+8 WRITE !,"9. Current Marital Status"
+9 WRITE ?55,"|9A. Spouse's Name (Last, First, MI)"
+10 WRITE !?3,@EAS3@(0),?55,"|",?61,@EAS3@(1),?131,$CHAR(13)
XECUTE EAINFO("L")
+11 ;
+12 WRITE !,"9B. Spouse Residing in the Community?"
+13 WRITE ?90,"|9C. Spouse's Social Security Number"
+14 WRITE !?4,@EAS3@(2),?90,"|",?95,@EAS3@(3),?131,$CHAR(13)
XECUTE EAINFO("L")
End DoDot:1
+15 ;
+16 IF '$GET(EAINFO("FORM"))
Begin DoDot:1
+17 WRITE !,"9. Spouse's Name (Last,First,MI)"
+18 WRITE !?3,@EAS3@(1),?131,$CHAR(13)
XECUTE EAINFO("L")
+19 ;
+20 WRITE !,"9A. Spouse Residing in the Community?"
+21 WRITE ?90,"|9B. Spouse's Social Security Number"
+22 WRITE !?4,@EAS3@(2),?90,"|",?95,@EAS3@(3),?131,$CHAR(13)
XECUTE EAINFO("L")
End DoDot:1
+23 ;
+24 ;loop through dependents
FOR X=4,8
Begin DoDot:1
+25 WRITE !,$SELECT(X=4:10,X=8:11)_". Dependent's Name (Last, First, MI)"
+26 WRITE ?55,"|",$SELECT(X=4:10,X=8:11)_"A. Dependent's Date of Birth"
+27 WRITE ?90,"|",$SELECT(X=4:10,X=8:11)_"B. Dependent's Social Security Number"
+28 WRITE !?4,@EAS3@(X),?55,"|",?61,@EAS3@(X+1),?90,"|",?96,@EAS3@(X+2),?131,$CHAR(13)
XECUTE EAINFO("L")
+29 ;
+30 WRITE !,$SELECT(X=4:10,X=8:11)_"C. Dependent Residing in the Community?"
+31 WRITE !?5,@EAS3@(X+3),?131,$CHAR(13)
XECUTE EAINFO("L")
End DoDot:1
+32 QUIT
DISCLAIM ;
+1 WRITE !,"We need to collect information regarding income, assets, and "
+2 WRITE "expenses for you and your spouse. If you do not wish to provide this"
+3 WRITE !,"information you must sign agreeing to make copayments and will "
+4 WRITE "be charged the maximum copayment amount for all services. See the"
+5 WRITE !,"top of page 2, read, sign, and date."
+6 QUIT
