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Routine: EASEZP61

Package: Enrollment Application System

Routine: EASEZP61


Information

EASEZP61 ;ALB/AMA,LBD - Print 1010EZ, Version 6 or greater, Cont. ; 1/28/13 2:27pm

Source Information

Source file <EASEZP61.m>

Entry Points

Name Comments DBIA/ICR reference
EN(EALNE,EAINFO) ;Entry point for VA 10-10EZ, Version 6 or greater, page 1
; Called from EN^EASEZP6F
DEM ; Print VA 10-10 Section I, Demographic information
II ; Print SECTION II - INSURANCE INFORMATION

Interaction Calls

Name Line Occurrences
Function Call: WRITE
  • Prompt: !!?50,"SECTION I - GENERAL INFORMATION"
  • Line Location: DEM+2
Function Call: WRITE
  • Prompt: ?131,$C(13)
  • Line Location: DEM+3
Function Call: WRITE
  • Prompt: !
  • Condition for execution: EALNE("ULC")="-"
  • Line Location: DEM+3
Function Call: WRITE
  • Prompt: EALNE("UL")
  • Line Location: DEM+3
Function Call: WRITE
  • Prompt: !?18,"Federal law provides criminal penalties, including a fine and/or imprisonment for up to 5 years,"
  • Line Location: DEM+4
Function Call: WRITE
  • Prompt: !?20,"for concealing a material fact or making a materially false statement. (See 18 U.S.C. 1001)"
  • Line Location: DEM+5
Function Call: WRITE
  • Prompt: ?131,$C(13)
  • Line Location: DEM+6
Function Call: WRITE
  • Prompt: !
  • Condition for execution: EALNE("ULC")="-"
  • Line Location: DEM+6
Function Call: WRITE
  • Prompt: EALNE("UL")
  • Line Location: DEM+6
Function Call: WRITE
  • Prompt: !,"1. VETERAN'S NAME (Last, First, Middle Name)",?50,"|2. OTHER NAMES USED",?87,"|3. MOTHER'S MAIDEN NAME",?121,"|4. GENDER"
  • Line Location: DEM+8
Function Call: WRITE
  • Prompt: !?3,@EASD@(2),?50,"| ",@EASD@(3),?87,"| ",@EASD@("3A"),?121,"| ",@EASD@(4)
  • Line Location: DEM+9
Function Call: WRITE
  • Prompt: ?131,$C(13)
  • Line Location: DEM+10
Function Call: WRITE
  • Prompt: !
  • Condition for execution: EALNE("ULC")="-"
  • Line Location: DEM+10
Function Call: WRITE
  • Prompt: EALNE("UL")
  • Line Location: DEM+10
Function Call: WRITE
  • Prompt: !,"5. ARE YOU SPANISH, HISPANIC,",?32,"|6. WHAT IS YOUR RACE? ",@EASD@("4B"),"AMERICAN INDIAN OR ALASKA NATIVE"
  • Line Location: DEM+12
Function Call: WRITE
  • Prompt: ?103,@EASD@("4C"),"BLACK OR AFRICAN AMERICAN"
  • Line Location: DEM+13
Function Call: WRITE
  • Prompt: !?3,"OR LATINO? ",@EASD@("4A"),?32,"|",?57,@EASD@("4E"),"ASIAN"
  • Line Location: DEM+14
Function Call: WRITE
  • Prompt: ?73,@EASD@("4F"),"WHITE",?87,@EASD@("4D"),"NATIVE HAWAIIAN OR OTHER PACIFIC ISLANDER"
  • Line Location: DEM+15
Function Call: WRITE
  • Prompt: ?131,$C(13)
  • Line Location: DEM+16
Function Call: WRITE
  • Prompt: !
  • Condition for execution: EALNE("ULC")="-"
  • Line Location: DEM+16
Function Call: WRITE
  • Prompt: EALNE("UL")
  • Line Location: DEM+16
Function Call: WRITE
  • Prompt: !,"7. SOCIAL SECURITY NUMBER",?32,"|8. VA CLAIM NUMBER",?87,"|9. DATE OF BIRTH (mm/dd/yyyy)"
  • Line Location: DEM+18
Function Call: WRITE
  • Prompt: !?3,@EASD@(5),?32,"| ",@EASD@(6),?87,"| ",@EASD@(7)
  • Line Location: DEM+19
Function Call: WRITE
  • Prompt: ?131,$C(13)
  • Line Location: DEM+20
Function Call: WRITE
  • Prompt: !
  • Condition for execution: EALNE("ULC")="-"
  • Line Location: DEM+20
Function Call: WRITE
  • Prompt: EALNE("UL")
  • Line Location: DEM+20
Function Call: WRITE
  • Prompt: !,"9A. PLACE OF BIRTH (City & State)",?87,"|10. RELIGION"
  • Line Location: DEM+22
Function Call: WRITE
  • Prompt: !?4,@EASD@("8A"),?87,"| ",@EASD@(8)
  • Line Location: DEM+23
Function Call: WRITE
  • Prompt: ?131,$C(13)
  • Line Location: DEM+24
Function Call: WRITE
  • Prompt: !
  • Condition for execution: EALNE("ULC")="-"
  • Line Location: DEM+24
Function Call: WRITE
  • Prompt: EALNE("UL")
  • Line Location: DEM+24
Function Call: WRITE
  • Prompt: !,"11. PERMANENT ADDRESS (Street)",?41,"|11A. CITY",?64,"|11B. STATE",?107,"|11C. ZIP CODE (9 digits)"
  • Line Location: DEM+28
Function Call: WRITE
  • Prompt: !?4,@EASD@("9A"),?41,"| ",@EASD@("9B"),?64,"| ",@EASD@("9C"),?107,"| ",@EASD@("9D")
  • Line Location: DEM+29
Function Call: WRITE
  • Prompt: ?131,$C(13)
  • Line Location: DEM+30
Function Call: WRITE
  • Prompt: !
  • Condition for execution: EALNE("ULC")="-"
  • Line Location: DEM+30
Function Call: WRITE
  • Prompt: EALNE("UL")
  • Line Location: DEM+30
Function Call: WRITE
  • Prompt: !,"11D. COUNTY",?35,"|11E. HOME TELEPHONE NUMBER (Include area code) |11F. E-MAIL ADDRESS"
  • Line Location: DEM+32
Function Call: WRITE
  • Prompt: !?5,@EASD@("9E"),?35,"| ",@EASD@(10),?84,"| ",@EASD@("11A")
  • Line Location: DEM+33
Function Call: WRITE
  • Prompt: !,"11. PERMANENT ADDRESS (Street)",?41,"|11A. CITY",?64,"|11B. PROVINCE",?107,"|11C. POSTAL CODE"
  • Line Location: DEM+36
Function Call: WRITE
  • Prompt: !?4,@EASD@("9A"),?41,"| ",@EASD@("9B"),?64,"| ",@EASD@("9F"),?107,"| ",@EASD@("9G")
  • Line Location: DEM+37
Function Call: WRITE
  • Prompt: ?131,$C(13)
  • Line Location: DEM+38
Function Call: WRITE
  • Prompt: !
  • Condition for execution: EALNE("ULC")="-"
  • Line Location: DEM+38
Function Call: WRITE
  • Prompt: EALNE("UL")
  • Line Location: DEM+38
Function Call: WRITE
  • Prompt: !,"11D. COUNTRY",?35,"|11E. HOME TELEPHONE NUMBER (Include area code) |11F. E-MAIL ADDRESS"
  • Line Location: DEM+40
Function Call: WRITE
  • Prompt: !?5,@EASD@("9H"),?35,"| ",@EASD@(10),?84,"| ",@EASD@("11A")
  • Line Location: DEM+41
Function Call: WRITE
  • Prompt: ?131,$C(13)
  • Line Location: DEM+43
Function Call: WRITE
  • Prompt: !
  • Condition for execution: EALNE("ULC")="-"
  • Line Location: DEM+43
Function Call: WRITE
  • Prompt: EALNE("UL")
  • Line Location: DEM+43
Function Call: WRITE
  • Prompt: !,"11G. CELLULAR TELEPHONE NUMBER (Include area code)",?66,"|12. TYPE OF BENEFIT(S) APPLYING FOR"
  • Line Location: DEM+45
Function Call: WRITE
  • Prompt: !?5,@EASD@("11G"),?66,"| ",@EASD@("1A")
  • Line Location: DEM+46
Function Call: WRITE
  • Prompt: ?131,$C(13)
  • Line Location: DEM+47
Function Call: WRITE
  • Prompt: !
  • Condition for execution: EALNE("ULC")="-"
  • Line Location: DEM+47
Function Call: WRITE
  • Prompt: EALNE("UL")
  • Line Location: DEM+47
Function Call: WRITE
  • Prompt: !,"13. WHICH VA MEDICAL CENTER OR OUTPATIENT CLINIC",?50,"|14. DO YOU WANT AN APPOINTMENT WITH A VA DOCTOR OR PROVIDER AS SOON AS ONE"
  • Line Location: DEM+49
Function Call: WRITE
  • Prompt: !?4,"DO YOU PREFER? ",@EASD@("1B"),?50,"| BECOMES AVAILABLE? ",@EASD@("11B")
  • Line Location: DEM+50
Function Call: WRITE
  • Prompt: " I am only enrolling in case I need care in the future."
  • Line Location: DEM+51
Function Call: WRITE
  • Prompt: ?131,$C(13)
  • Line Location: DEM+52
Function Call: WRITE
  • Prompt: !
  • Condition for execution: EALNE("ULC")="-"
  • Line Location: DEM+52
Function Call: WRITE
  • Prompt: EALNE("UL")
  • Line Location: DEM+52
Function Call: WRITE
  • Prompt: !,"15. CURRENT MARITAL STATUS ",@EASD@(12)
  • Line Location: DEM+54
Function Call: WRITE
  • Prompt: ?131,$C(13)
  • Line Location: DEM+55
Function Call: WRITE
  • Prompt: !
  • Condition for execution: EALNE("ULC")="-"
  • Line Location: DEM+55
Function Call: WRITE
  • Prompt: EALNE("UL")
  • Line Location: DEM+55
Function Call: WRITE
  • Prompt: !,"16. NAME, ADDRESS AND RELATIONSHIP OF NEXT OF KIN",?83,"|16A. NEXT OF KIN'S HOME TELEPHONE NUMBER"
  • Line Location: DEM+57
Function Call: WRITE
  • Prompt: !?4,$P(@EASD@("19A"),U)," - ",$P(@EASD@("19A"),U,4),?83,"| (Include area code) ",@EASD@("19B")
  • Line Location: DEM+58
Function Call: WRITE
  • Prompt: ?131,$C(13)
  • Line Location: DEM+59
Function Call: WRITE
  • Prompt: !
  • Condition for execution: EALNE("ULC")="-"
  • Line Location: DEM+59
Function Call: WRITE
  • Prompt: " "
  • Line Location: DEM+59
Function Call: WRITE
  • Prompt: $E(EALNE("UL"),1,48)
  • Line Location: DEM+60
Function Call: WRITE
  • Prompt: !?4,$P(@EASD@("19A"),U,2),?83,"|16B. NEXT OF KIN'S WORK TELEPHONE NUMBER"
  • Line Location: DEM+61
Function Call: WRITE
  • Prompt: !?4,$P(@EASD@("19A"),U,3),?83,"| (Include area code) ",@EASD@("19C")
  • Line Location: DEM+62
Function Call: WRITE
  • Prompt: ?131,$C(13)
  • Line Location: DEM+63
Function Call: WRITE
  • Prompt: !
  • Condition for execution: EALNE("ULC")="-"
  • Line Location: DEM+63
Function Call: WRITE
  • Prompt: EALNE("UL")
  • Line Location: DEM+63
Function Call: WRITE
  • Prompt: !,"17. NAME, ADDRESS AND RELATIONSHIP OF EMERGENCY CONTACT",?83,"|17A. EMERGENCY CONTACT'S HOME TELEPHONE NUMBER"
  • Line Location: DEM+65
Function Call: WRITE
  • Prompt: !?4,$P(@EASD@("20A"),U)," - ",$P(@EASD@("20A"),U,4),?83,"| (Include area code) ",@EASD@("20B")
  • Line Location: DEM+66
Function Call: WRITE
  • Prompt: ?131,$C(13)
  • Line Location: DEM+67
Function Call: WRITE
  • Prompt: !
  • Condition for execution: EALNE("ULC")="-"
  • Line Location: DEM+67
Function Call: WRITE
  • Prompt: " "
  • Line Location: DEM+67
Function Call: WRITE
  • Prompt: $E(EALNE("UL"),1,48)
  • Line Location: DEM+68
Function Call: WRITE
  • Prompt: !?4,$P(@EASD@("20A"),U,2),?83,"|17B. EMERGENCY CONTACT'S WORK TELEPHONE NUMBER"
  • Line Location: DEM+69
Function Call: WRITE
  • Prompt: !?4,$P(@EASD@("20A"),U,3),?83,"| (Include area code) ",@EASD@("20C")
  • Line Location: DEM+70
Function Call: WRITE
  • Prompt: ?131,$C(13)
  • Line Location: DEM+71
Function Call: WRITE
  • Prompt: !
  • Condition for execution: EALNE("ULC")="-"
  • Line Location: DEM+71
Function Call: WRITE
  • Prompt: EALNE("UL")
  • Line Location: DEM+71
Function Call: WRITE
  • Prompt: !!?25,"SECTION II - INSURANCE INFORMATION (Use Separate Sheet for Additional Insurance)"
  • Line Location: II+2
Function Call: WRITE
  • Prompt: ?131,$C(13)
  • Line Location: II+3
Function Call: WRITE
  • Prompt: !
  • Condition for execution: EALNE("ULC")="-"
  • Line Location: II+3
Function Call: WRITE
  • Prompt: EALNE("UL")
  • Line Location: II+3
Function Call: WRITE
  • Prompt: !,"1. HEALTH INSURANCE COMPANY NAME, ADDRESS AND TELEPHONE NUMBER"
  • Line Location: II+5
Function Call: WRITE
  • Prompt: " (include coverage through spouse or other person)"
  • Line Location: II+6
Function Call: WRITE
  • Prompt: !," ",@EASD@("17A"),?50,@EASD@("17J")
  • Line Location: II+7
Function Call: WRITE
  • Prompt: !," ",@EASD@("17E"),", ",@EASD@("17F"),", ",@EASD@("17G")," ",@EASD@("17H")
  • Line Location: II+8
Function Call: WRITE
  • Prompt: ?131,$C(13)
  • Line Location: II+9
Function Call: WRITE
  • Prompt: !
  • Condition for execution: EALNE("ULC")="-"
  • Line Location: II+9
Function Call: WRITE
  • Prompt: EALNE("UL")
  • Line Location: II+9
Function Call: WRITE
  • Prompt: !,"2. NAME OF POLICY HOLDER",?33,"|3. POLICY NUMBER",?57,"|4. GROUP CODE"
  • Line Location: II+11
Function Call: WRITE
  • Prompt: ?78,"|5. ARE YOU ELIG. FOR MEDICAID?",?112,"|5A. EFFECTIVE DATE"
  • Line Location: II+12
Function Call: WRITE
  • Prompt: !?3,@EASD@("17B"),?33,"| ",@EASD@("17C"),?57,"| ",@EASD@("17D")
  • Line Location: II+13
Function Call: WRITE
  • Prompt: ?78,"| ",@EASD@("14J"),?112,"|"
  • Line Location: II+14
Function Call: WRITE
  • Prompt: ?131,$C(13)
  • Line Location: II+15
Function Call: WRITE
  • Prompt: !
  • Condition for execution: EALNE("ULC")="-"
  • Line Location: II+15
Function Call: WRITE
  • Prompt: EALNE("UL")
  • Line Location: II+15
Function Call: WRITE
  • Prompt: !,"6. ARE YOU ENROLLED IN MEDICARE HOSPITAL INSURANCE PART A? ",@EASD@("14K"),?75,"|6A. EFFECTIVE DATE (mm/dd/yyyy) ",@EASD@("14K1")
  • Line Location: II+17
Function Call: WRITE
  • Prompt: ?131,$C(13)
  • Line Location: II+18
Function Call: WRITE
  • Prompt: !
  • Condition for execution: EALNE("ULC")="-"
  • Line Location: II+18
Function Call: WRITE
  • Prompt: EALNE("UL")
  • Line Location: II+18
Function Call: WRITE
  • Prompt: !,"7. ARE YOU ENROLLED IN MEDICARE HOSPITAL INSURANCE PART B? ",@EASD@("14L"),?75,"|7A. EFFECTIVE DATE (mm/dd/yyyy) ",@EASD@("14L1")
  • Line Location: II+20
Function Call: WRITE
  • Prompt: ?131,$C(13)
  • Line Location: II+21
Function Call: WRITE
  • Prompt: !
  • Condition for execution: EALNE("ULC")="-"
  • Line Location: II+21
Function Call: WRITE
  • Prompt: EALNE("UL")
  • Line Location: II+21
Function Call: WRITE
  • Prompt: !,"8. NAME EXACTLY AS IT APPEARS ON YOUR MEDICARE CARD",?70,"|9. MEDICARE CLAIM NUMBER"
  • Line Location: II+23
Function Call: WRITE
  • Prompt: !?3,@EASD@("14N"),?70,"| ",@EASD@("14M")
  • Line Location: II+24
Function Call: WRITE
  • Prompt: ?131,$C(13)
  • Line Location: II+25
Function Call: WRITE
  • Prompt: !
  • Condition for execution: EALNE("ULC")="-"
  • Line Location: II+25
Function Call: WRITE
  • Prompt: EALNE("UL")
  • Line Location: II+25
Info |  Source |  Entry Points |  Interaction Calls