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 09, 2024@20:59:22 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
