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Routine: EASEC103

Package: Enrollment Application System

Routine: EASEC103


Information

EASEC103 ;ALB/BRM,LBD - Print 1010EC LTC Enrollment form ; 9/7/01 9:49am

Source Information

Source file <EASEC103.m>

Entry Points

Name Comments DBIA/ICR reference
PAGE3(EALNE,EAINFO,EASDFN) ;Print page 3
SEC6 ; print section 6 - Expenses
SEC7 ;print section 7 - Consent for Assignment of Benefits
SEC8 ;print section 8 - Consent and Agreement to make copayments

Interaction Calls

Name Line Occurrences
Function Call: WRITE
  • Prompt: !?55,"SECTION VI - EXPENSES",!,EALNE("D")
  • Line Location: SEC6+4
Function Call: WRITE
  • Prompt: !?54,"ITEMS",?113,"|",?119,"AMOUNT",?131,$C(13)
  • Line Location: SEC6+5
Function Call: WRITE
  • Prompt: !,"1. Education (veteran, spouse or dependent)",?113,"| $",$J(@EAS6@(1),10,2),?131,$C(13)
  • Line Location: SEC6+6
Function Call: WRITE
  • Prompt: !,"2. Funeral and Burial (spouse or child)",?113,"| $",$J(@EAS6@(2),10,2),?131,$C(13)
  • Line Location: SEC6+7
Function Call: WRITE
  • Prompt: !,"3. Rent/Mortgage",?113,"| $",$J(@EAS6@(3),10,2),?131,$C(13)
  • Line Location: SEC6+8
Function Call: WRITE
  • Prompt: !,"4. Utilities",?113,"| $",$J(@EAS6@(4),10,2),?131,$C(13)
  • Line Location: SEC6+9
Function Call: WRITE
  • Prompt: !,"5. Car Payment Only (excludes gas, insurance, parking fees)",?113,"| $",$J(@EAS6@(5),10,2),?131,$C(13)
  • Line Location: SEC6+10
Function Call: WRITE
  • Prompt: !,"6. Food",?113,"| $",$J(@EAS6@(6),10,2),?131,$C(13)
  • Line Location: SEC6+11
Function Call: WRITE
  • Prompt: !,"7. Non-reimbursed medical expenses",?113,"| $",$J(@EAS6@(7),10,2),?131,$C(13)
  • Line Location: SEC6+12
Function Call: WRITE
  • Prompt: !,"8. Court-ordered payments",?113,"| $",$J(@EAS6@(8),10,2),?131,$C(13)
  • Line Location: SEC6+13
Function Call: WRITE
  • Prompt: !,"9. Insurance (exclude life insurance)",?113,"| $",$J(@EAS6@(9),10,2),?131,$C(13)
  • Line Location: SEC6+14
Function Call: WRITE
  • Prompt: !,"10. Taxes (on any amount include in gross income, property, personal)",?113,"| $",$J(@EAS6@(10),10,2),?131,$C(13)
  • Line Location: SEC6+15
Function Call: WRITE
  • Prompt: !,?95,"| TOTAL",?113,"| $",$J(@EAS6@(11),10,2),?131,$C(13)
  • Line Location: SEC6+16
Function Call: WRITE
  • Prompt: !?42,"SECTION ",SECN," - CONSENT FOR ASSIGNMENT OF BENEFITS",!,EALNE("D")
  • Line Location: SEC7+3
Function Call: WRITE
  • Prompt: !,"I hereby authorize the Department of Veterans Affairs to disclose any such history, diagnostic and treatment information from my"
  • Line Location: SEC7+4
Function Call: WRITE
  • Prompt: !,"medical records to the contractor of any health plan contract under which I am apparently eligible for medical care or payment of"
  • Line Location: SEC7+5
Function Call: WRITE
  • Prompt: !,"the expense of care or to any other party against whom liability is asserted. I understand that I may revoke this authorization at"
  • Line Location: SEC7+6
Function Call: WRITE
  • Prompt: !,"any time, except to the extent that action has already been taken in reliance on it. Without my express revocation, this consent"
  • Line Location: SEC7+7
Function Call: WRITE
  • Prompt: !,"will automatically expire when all action arising from VA's claim for reimbursement from my medical care has been completed."
  • Line Location: SEC7+8
Function Call: WRITE
  • Prompt: !,"I authorize payment of medical benefits to VA for any services for which payment is accepted.",?131,$C(13)
  • Line Location: SEC7+9
Function Call: WRITE
  • Prompt: !,"Signature",?100,"| Date",!?100,"|",?131,$C(13)
  • Line Location: SEC7+10
Function Call: WRITE
  • Prompt: !?39,"SECTION ",SECN," - CONSENT AND AGREEMENT TO MAKE COPAYMENTS",!,EALNE("D")
  • Line Location: SEC8+4
Function Call: WRITE
  • Prompt: !,"Completion of this form with signature of the Veteran or veteran's representative is certification that the veteran/representative"
  • Line Location: SEC8+5
Function Call: WRITE
  • Prompt: !,"has received a copy of the Privacy Act Statement and agrees to make appropriate copayments."
  • Line Location: SEC8+6
Function Call: WRITE
  • Prompt: !!,"I certify the foregoing statement(s) are true and correct to the best of my knowledge and belief and agree to make the applicable"
  • Line Location: SEC8+7
Function Call: WRITE
  • Prompt: !,"copayment for extended care services as required by law.",?131,$C(13)
  • Line Location: SEC8+8
Function Call: WRITE
  • Prompt: !,"Signature",?100,"| Date",!?100,"|",?131,$C(13)
  • Line Location: SEC8+9
Function Call: WRITE
  • Prompt: !,"Additional Comments:"
  • Line Location: SEC8+11
Function Call: WRITE
  • Prompt: !,@EAS8@(WPLINE)
  • Line Location: SEC8+13
Function Call: WRITE
  • Prompt: !
  • Line Location: SEC8+14
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