- EASEC103 ;ALB/BRM,LBD - Print 1010EC LTC Enrollment form ; 9/7/01 9:49am
- ;;1.0;ENROLLMENT APPLICATION SYSTEM;**5,7,40**;Mar 15, 2001
- ;
- ; Called from ^EASEC10E to print page 3 of the 1010EC
- ;
- PAGE3(EALNE,EAINFO,EASDFN) ;Print page 3
- N X,EASROOT
- S EASROOT="^TMP(""1010EC"",$J,"_EASDFN_","
- D HDR^EASEC10E(.EALNE,.EAINFO)
- D SEC6
- D SEC7
- D SEC8
- D FT^EASEC10E(.EALNE,.EAINFO)
- Q
- ;
- SEC6 ; print section 6 - Expenses
- N EAS6
- S EAS6=EASROOT_"6)"
- ;
- W !?55,"SECTION VI - EXPENSES",!,EALNE("D")
- W !?54,"ITEMS",?113,"|",?119,"AMOUNT",?131,$C(13) X EAINFO("L")
- W !,"1. Education (veteran, spouse or dependent)",?113,"| $",$J(@EAS6@(1),10,2),?131,$C(13) X EAINFO("L")
- W !,"2. Funeral and Burial (spouse or child)",?113,"| $",$J(@EAS6@(2),10,2),?131,$C(13) X EAINFO("L")
- W !,"3. Rent/Mortgage",?113,"| $",$J(@EAS6@(3),10,2),?131,$C(13) X EAINFO("L")
- W !,"4. Utilities",?113,"| $",$J(@EAS6@(4),10,2),?131,$C(13) X EAINFO("L")
- W !,"5. Car Payment Only (excludes gas, insurance, parking fees)",?113,"| $",$J(@EAS6@(5),10,2),?131,$C(13) X EAINFO("L")
- W !,"6. Food",?113,"| $",$J(@EAS6@(6),10,2),?131,$C(13) X EAINFO("L")
- W !,"7. Non-reimbursed medical expenses",?113,"| $",$J(@EAS6@(7),10,2),?131,$C(13) X EAINFO("L")
- W !,"8. Court-ordered payments",?113,"| $",$J(@EAS6@(8),10,2),?131,$C(13) X EAINFO("L")
- W !,"9. Insurance (exclude life insurance)",?113,"| $",$J(@EAS6@(9),10,2),?131,$C(13) X EAINFO("L")
- W !,"10. Taxes (on any amount include in gross income, property, personal)",?113,"| $",$J(@EAS6@(10),10,2),?131,$C(13) X EAINFO("L")
- W !,?95,"| TOTAL",?113,"| $",$J(@EAS6@(11),10,2),?131,$C(13) X EAINFO("L")
- Q
- SEC7 ;print section 7 - Consent for Assignment of Benefits
- N SECN
- S SECN=$S($G(EAINFO("FORM")):"VIII",1:"VII") ;Added for LTC Phase IV
- W !?42,"SECTION ",SECN," - CONSENT FOR ASSIGNMENT OF BENEFITS",!,EALNE("D")
- W !,"I hereby authorize the Department of Veterans Affairs to disclose any such history, diagnostic and treatment information from my"
- W !,"medical records to the contractor of any health plan contract under which I am apparently eligible for medical care or payment of"
- W !,"the expense of care or to any other party against whom liability is asserted. I understand that I may revoke this authorization at"
- W !,"any time, except to the extent that action has already been taken in reliance on it. Without my express revocation, this consent"
- W !,"will automatically expire when all action arising from VA's claim for reimbursement from my medical care has been completed."
- W !,"I authorize payment of medical benefits to VA for any services for which payment is accepted.",?131,$C(13) X EAINFO("L")
- W !,"Signature",?100,"| Date",!?100,"|",?131,$C(13) X EAINFO("L")
- Q
- SEC8 ;print section 8 - Consent and Agreement to make copayments
- N I,WPLINE,EAS8,WPCNT,SECN
- S EAS8=EASROOT_"8)",WPLINE=0,WPCNT=1
- S SECN=$S($G(EAINFO("FORM")):"IX",1:"VIII") ; Added for LTC Phase IV
- W !?39,"SECTION ",SECN," - CONSENT AND AGREEMENT TO MAKE COPAYMENTS",!,EALNE("D")
- W !,"Completion of this form with signature of the Veteran or veteran's representative is certification that the veteran/representative"
- W !,"has received a copy of the Privacy Act Statement and agrees to make appropriate copayments."
- W !!,"I certify the foregoing statement(s) are true and correct to the best of my knowledge and belief and agree to make the applicable"
- W !,"copayment for extended care services as required by law.",?131,$C(13) X EAINFO("L")
- W !,"Signature",?100,"| Date",!?100,"|",?131,$C(13) X EAINFO("L")
- Q:$G(EAINFO("FORM")) ;Added for LTC Phase IV (EAS*1*40)
- W !,"Additional Comments:"
- D:$D(EAS8)
- .F S WPLINE=$O(@EAS8@(WPLINE)) Q:'WPLINE S WPCNT=WPCNT+1 W !,@EAS8@(WPLINE)
- F I=WPCNT:1:14 W !
- Q
- --- Routine Detail --- with STRUCTURED ROUTINE LISTING ---[H[J[2J[HEASEC103 3799 printed Apr 23, 2025@18:08:14 Page 2
- EASEC103 ;ALB/BRM,LBD - Print 1010EC LTC Enrollment form ; 9/7/01 9:49am
- +1 ;;1.0;ENROLLMENT APPLICATION SYSTEM;**5,7,40**;Mar 15, 2001
- +2 ;
- +3 ; Called from ^EASEC10E to print page 3 of the 1010EC
- +4 ;
- PAGE3(EALNE,EAINFO,EASDFN) ;Print page 3
- +1 NEW X,EASROOT
- +2 SET EASROOT="^TMP(""1010EC"",$J,"_EASDFN_","
- +3 DO HDR^EASEC10E(.EALNE,.EAINFO)
- +4 DO SEC6
- +5 DO SEC7
- +6 DO SEC8
- +7 DO FT^EASEC10E(.EALNE,.EAINFO)
- +8 QUIT
- +9 ;
- SEC6 ; print section 6 - Expenses
- +1 NEW EAS6
- +2 SET EAS6=EASROOT_"6)"
- +3 ;
- +4 WRITE !?55,"SECTION VI - EXPENSES",!,EALNE("D")
- +5 WRITE !?54,"ITEMS",?113,"|",?119,"AMOUNT",?131,$CHAR(13)
- XECUTE EAINFO("L")
- +6 WRITE !,"1. Education (veteran, spouse or dependent)",?113,"| $",$JUSTIFY(@EAS6@(1),10,2),?131,$CHAR(13)
- XECUTE EAINFO("L")
- +7 WRITE !,"2. Funeral and Burial (spouse or child)",?113,"| $",$JUSTIFY(@EAS6@(2),10,2),?131,$CHAR(13)
- XECUTE EAINFO("L")
- +8 WRITE !,"3. Rent/Mortgage",?113,"| $",$JUSTIFY(@EAS6@(3),10,2),?131,$CHAR(13)
- XECUTE EAINFO("L")
- +9 WRITE !,"4. Utilities",?113,"| $",$JUSTIFY(@EAS6@(4),10,2),?131,$CHAR(13)
- XECUTE EAINFO("L")
- +10 WRITE !,"5. Car Payment Only (excludes gas, insurance, parking fees)",?113,"| $",$JUSTIFY(@EAS6@(5),10,2),?131,$CHAR(13)
- XECUTE EAINFO("L")
- +11 WRITE !,"6. Food",?113,"| $",$JUSTIFY(@EAS6@(6),10,2),?131,$CHAR(13)
- XECUTE EAINFO("L")
- +12 WRITE !,"7. Non-reimbursed medical expenses",?113,"| $",$JUSTIFY(@EAS6@(7),10,2),?131,$CHAR(13)
- XECUTE EAINFO("L")
- +13 WRITE !,"8. Court-ordered payments",?113,"| $",$JUSTIFY(@EAS6@(8),10,2),?131,$CHAR(13)
- XECUTE EAINFO("L")
- +14 WRITE !,"9. Insurance (exclude life insurance)",?113,"| $",$JUSTIFY(@EAS6@(9),10,2),?131,$CHAR(13)
- XECUTE EAINFO("L")
- +15 WRITE !,"10. Taxes (on any amount include in gross income, property, personal)",?113,"| $",$JUSTIFY(@EAS6@(10),10,2),?131,$CHAR(13)
- XECUTE EAINFO("L")
- +16 WRITE !,?95,"| TOTAL",?113,"| $",$JUSTIFY(@EAS6@(11),10,2),?131,$CHAR(13)
- XECUTE EAINFO("L")
- +17 QUIT
- SEC7 ;print section 7 - Consent for Assignment of Benefits
- +1 NEW SECN
- +2 ;Added for LTC Phase IV
- SET SECN=$SELECT($GET(EAINFO("FORM")):"VIII",1:"VII")
- +3 WRITE !?42,"SECTION ",SECN," - CONSENT FOR ASSIGNMENT OF BENEFITS",!,EALNE("D")
- +4 WRITE !,"I hereby authorize the Department of Veterans Affairs to disclose any such history, diagnostic and treatment information from my"
- +5 WRITE !,"medical records to the contractor of any health plan contract under which I am apparently eligible for medical care or payment of"
- +6 WRITE !,"the expense of care or to any other party against whom liability is asserted. I understand that I may revoke this authorization at"
- +7 WRITE !,"any time, except to the extent that action has already been taken in reliance on it. Without my express revocation, this consent"
- +8 WRITE !,"will automatically expire when all action arising from VA's claim for reimbursement from my medical care has been completed."
- +9 WRITE !,"I authorize payment of medical benefits to VA for any services for which payment is accepted.",?131,$CHAR(13)
- XECUTE EAINFO("L")
- +10 WRITE !,"Signature",?100,"| Date",!?100,"|",?131,$CHAR(13)
- XECUTE EAINFO("L")
- +11 QUIT
- SEC8 ;print section 8 - Consent and Agreement to make copayments
- +1 NEW I,WPLINE,EAS8,WPCNT,SECN
- +2 SET EAS8=EASROOT_"8)"
- SET WPLINE=0
- SET WPCNT=1
- +3 ; Added for LTC Phase IV
- SET SECN=$SELECT($GET(EAINFO("FORM")):"IX",1:"VIII")
- +4 WRITE !?39,"SECTION ",SECN," - CONSENT AND AGREEMENT TO MAKE COPAYMENTS",!,EALNE("D")
- +5 WRITE !,"Completion of this form with signature of the Veteran or veteran's representative is certification that the veteran/representative"
- +6 WRITE !,"has received a copy of the Privacy Act Statement and agrees to make appropriate copayments."
- +7 WRITE !!,"I certify the foregoing statement(s) are true and correct to the best of my knowledge and belief and agree to make the applicable"
- +8 WRITE !,"copayment for extended care services as required by law.",?131,$CHAR(13)
- XECUTE EAINFO("L")
- +9 WRITE !,"Signature",?100,"| Date",!?100,"|",?131,$CHAR(13)
- XECUTE EAINFO("L")
- +10 ;Added for LTC Phase IV (EAS*1*40)
- if $GET(EAINFO("FORM"))
- QUIT
- +11 WRITE !,"Additional Comments:"
- +12 if $DATA(EAS8)
- Begin DoDot:1
- +13 FOR
- SET WPLINE=$ORDER(@EAS8@(WPLINE))
- if 'WPLINE
- QUIT
- SET WPCNT=WPCNT+1
- WRITE !,@EAS8@(WPLINE)
- End DoDot:1
- +14 FOR I=WPCNT:1:14
- WRITE !
- +15 QUIT
