EASEZP61 ;ALB/AMA,LBD - Print 1010EZ, Version 6 or greater, Cont. ; 1/28/13 2:27pm
;;1.0;ENROLLMENT APPLICATION SYSTEM;**51,60,70,107**;Mar 15, 2001;Build 32
;
; This routine copied from EASEZPF1; if the version # of the 1010EZ
; application is 6.0 or greater, then this routine will be executed.
;
EN(EALNE,EAINFO) ;Entry point for VA 10-10EZ, Version 6 or greater, page 1
; Called from EN^EASEZP6F
N X,EASD
;
S EASD=$NA(^TMP("EASEZ",$J,1))
D HDRMAIN^EASEZP6F(.EALNE)
D DEM
;
D FT^EASEZP6F(.EALNE,.EAINFO)
S EAINFO("VET")=@EASD@(2),EAINFO("SSN")=@EASD@(5)
Q
;
DEM ; Print VA 10-10 Section I, Demographic information
;
W !!?50,"SECTION I - GENERAL INFORMATION"
W ?131,$C(13) W:EALNE("ULC")="-" ! W EALNE("UL")
W !?18,"Federal law provides criminal penalties, including a fine and/or imprisonment for up to 5 years,"
W !?20,"for concealing a material fact or making a materially false statement. (See 18 U.S.C. 1001)"
W ?131,$C(13) W:EALNE("ULC")="-" ! W EALNE("UL")
;
W !,"1. VETERAN'S NAME (Last, First, Middle Name)",?50,"|2. OTHER NAMES USED",?87,"|3. MOTHER'S MAIDEN NAME",?121,"|4. GENDER"
W !?3,@EASD@(2),?50,"| ",@EASD@(3),?87,"| ",@EASD@("3A"),?121,"| ",@EASD@(4)
W ?131,$C(13) W:EALNE("ULC")="-" ! W EALNE("UL")
;
W !,"5. ARE YOU SPANISH, HISPANIC,",?32,"|6. WHAT IS YOUR RACE? ",@EASD@("4B"),"AMERICAN INDIAN OR ALASKA NATIVE"
W ?103,@EASD@("4C"),"BLACK OR AFRICAN AMERICAN"
W !?3,"OR LATINO? ",@EASD@("4A"),?32,"|",?57,@EASD@("4E"),"ASIAN"
W ?73,@EASD@("4F"),"WHITE",?87,@EASD@("4D"),"NATIVE HAWAIIAN OR OTHER PACIFIC ISLANDER"
W ?131,$C(13) W:EALNE("ULC")="-" ! W EALNE("UL")
;
W !,"7. SOCIAL SECURITY NUMBER",?32,"|8. VA CLAIM NUMBER",?87,"|9. DATE OF BIRTH (mm/dd/yyyy)"
W !?3,@EASD@(5),?32,"| ",@EASD@(6),?87,"| ",@EASD@(7)
W ?131,$C(13) W:EALNE("ULC")="-" ! W EALNE("UL")
;
W !,"9A. PLACE OF BIRTH (City & State)",?87,"|10. RELIGION"
W !?4,@EASD@("8A"),?87,"| ",@EASD@(8)
W ?131,$C(13) W:EALNE("ULC")="-" ! W EALNE("UL")
;
;EAS*1.0*70
I $G(@EASD@("9H"))="UNITED STATES" D I 1 ;Use domestic address field labels
. W !,"11. PERMANENT ADDRESS (Street)",?41,"|11A. CITY",?64,"|11B. STATE",?107,"|11C. ZIP CODE (9 digits)"
. W !?4,@EASD@("9A"),?41,"| ",@EASD@("9B"),?64,"| ",@EASD@("9C"),?107,"| ",@EASD@("9D")
. W ?131,$C(13) W:EALNE("ULC")="-" ! W EALNE("UL")
. ;
. W !,"11D. COUNTY",?35,"|11E. HOME TELEPHONE NUMBER (Include area code) |11F. E-MAIL ADDRESS"
. W !?5,@EASD@("9E"),?35,"| ",@EASD@(10),?84,"| ",@EASD@("11A")
;
E D ;Use foreign address field labels
. W !,"11. PERMANENT ADDRESS (Street)",?41,"|11A. CITY",?64,"|11B. PROVINCE",?107,"|11C. POSTAL CODE"
. W !?4,@EASD@("9A"),?41,"| ",@EASD@("9B"),?64,"| ",@EASD@("9F"),?107,"| ",@EASD@("9G")
. W ?131,$C(13) W:EALNE("ULC")="-" ! W EALNE("UL")
. ;
. W !,"11D. COUNTRY",?35,"|11E. HOME TELEPHONE NUMBER (Include area code) |11F. E-MAIL ADDRESS"
. W !?5,@EASD@("9H"),?35,"| ",@EASD@(10),?84,"| ",@EASD@("11A")
;
W ?131,$C(13) W:EALNE("ULC")="-" ! W EALNE("UL")
;
W !,"11G. CELLULAR TELEPHONE NUMBER (Include area code)",?66,"|12. TYPE OF BENEFIT(S) APPLYING FOR"
W !?5,@EASD@("11G"),?66,"| ",@EASD@("1A")
W ?131,$C(13) W:EALNE("ULC")="-" ! W EALNE("UL")
;
W !,"13. WHICH VA MEDICAL CENTER OR OUTPATIENT CLINIC",?50,"|14. DO YOU WANT AN APPOINTMENT WITH A VA DOCTOR OR PROVIDER AS SOON AS ONE"
W !?4,"DO YOU PREFER? ",@EASD@("1B"),?50,"| BECOMES AVAILABLE? ",@EASD@("11B")
I @EASD@("11B")="NO" W " I am only enrolling in case I need care in the future."
W ?131,$C(13) W:EALNE("ULC")="-" ! W EALNE("UL")
;
W !,"15. CURRENT MARITAL STATUS ",@EASD@(12)
W ?131,$C(13) W:EALNE("ULC")="-" ! W EALNE("UL")
;
W !,"16. NAME, ADDRESS AND RELATIONSHIP OF NEXT OF KIN",?83,"|16A. NEXT OF KIN'S HOME TELEPHONE NUMBER"
W !?4,$P(@EASD@("19A"),U)," - ",$P(@EASD@("19A"),U,4),?83,"| (Include area code) ",@EASD@("19B")
W ?131,$C(13) W:EALNE("ULC")="-" ! F X=1:1:84 W " "
W $E(EALNE("UL"),1,48)
W !?4,$P(@EASD@("19A"),U,2),?83,"|16B. NEXT OF KIN'S WORK TELEPHONE NUMBER"
W !?4,$P(@EASD@("19A"),U,3),?83,"| (Include area code) ",@EASD@("19C")
W ?131,$C(13) W:EALNE("ULC")="-" ! W EALNE("UL")
;
W !,"17. NAME, ADDRESS AND RELATIONSHIP OF EMERGENCY CONTACT",?83,"|17A. EMERGENCY CONTACT'S HOME TELEPHONE NUMBER"
W !?4,$P(@EASD@("20A"),U)," - ",$P(@EASD@("20A"),U,4),?83,"| (Include area code) ",@EASD@("20B")
W ?131,$C(13) W:EALNE("ULC")="-" ! F X=1:1:84 W " "
W $E(EALNE("UL"),1,48)
W !?4,$P(@EASD@("20A"),U,2),?83,"|17B. EMERGENCY CONTACT'S WORK TELEPHONE NUMBER"
W !?4,$P(@EASD@("20A"),U,3),?83,"| (Include area code) ",@EASD@("20C")
W ?131,$C(13) W:EALNE("ULC")="-" ! W EALNE("UL")
;
II ; Print SECTION II - INSURANCE INFORMATION
;
W !!?25,"SECTION II - INSURANCE INFORMATION (Use Separate Sheet for Additional Insurance)"
W ?131,$C(13) W:EALNE("ULC")="-" ! W EALNE("UL")
;
W !,"1. HEALTH INSURANCE COMPANY NAME, ADDRESS AND TELEPHONE NUMBER"
W " (include coverage through spouse or other person)"
W !," ",@EASD@("17A"),?50,@EASD@("17J")
I @EASD@("17E")'="" W !," ",@EASD@("17E"),", ",@EASD@("17F"),", ",@EASD@("17G")," ",@EASD@("17H")
W ?131,$C(13) W:EALNE("ULC")="-" ! W EALNE("UL")
;
W !,"2. NAME OF POLICY HOLDER",?33,"|3. POLICY NUMBER",?57,"|4. GROUP CODE"
W ?78,"|5. ARE YOU ELIG. FOR MEDICAID?",?112,"|5A. EFFECTIVE DATE"
W !?3,@EASD@("17B"),?33,"| ",@EASD@("17C"),?57,"| ",@EASD@("17D")
W ?78,"| ",@EASD@("14J"),?112,"|"
W ?131,$C(13) W:EALNE("ULC")="-" ! W EALNE("UL")
;
W !,"6. ARE YOU ENROLLED IN MEDICARE HOSPITAL INSURANCE PART A? ",@EASD@("14K"),?75,"|6A. EFFECTIVE DATE (mm/dd/yyyy) ",@EASD@("14K1")
W ?131,$C(13) W:EALNE("ULC")="-" ! W EALNE("UL")
;
W !,"7. ARE YOU ENROLLED IN MEDICARE HOSPITAL INSURANCE PART B? ",@EASD@("14L"),?75,"|7A. EFFECTIVE DATE (mm/dd/yyyy) ",@EASD@("14L1")
W ?131,$C(13) W:EALNE("ULC")="-" ! W EALNE("UL")
;
W !,"8. NAME EXACTLY AS IT APPEARS ON YOUR MEDICARE CARD",?70,"|9. MEDICARE CLAIM NUMBER"
W !?3,@EASD@("14N"),?70,"| ",@EASD@("14M")
W ?131,$C(13) W:EALNE("ULC")="-" ! W EALNE("UL")
;
Q
--- Routine Detail --- with STRUCTURED ROUTINE LISTING ---[H[J[2J[HEASEZP61 6241 printed Dec 13, 2024@01:54:39 Page 2
EASEZP61 ;ALB/AMA,LBD - Print 1010EZ, Version 6 or greater, Cont. ; 1/28/13 2:27pm
+1 ;;1.0;ENROLLMENT APPLICATION SYSTEM;**51,60,70,107**;Mar 15, 2001;Build 32
+2 ;
+3 ; This routine copied from EASEZPF1; if the version # of the 1010EZ
+4 ; application is 6.0 or greater, then this routine will be executed.
+5 ;
EN(EALNE,EAINFO) ;Entry point for VA 10-10EZ, Version 6 or greater, page 1
+1 ; Called from EN^EASEZP6F
+2 NEW X,EASD
+3 ;
+4 SET EASD=$NAME(^TMP("EASEZ",$JOB,1))
+5 DO HDRMAIN^EASEZP6F(.EALNE)
+6 DO DEM
+7 ;
+8 DO FT^EASEZP6F(.EALNE,.EAINFO)
+9 SET EAINFO("VET")=@EASD@(2)
SET EAINFO("SSN")=@EASD@(5)
+10 QUIT
+11 ;
DEM ; Print VA 10-10 Section I, Demographic information
+1 ;
+2 WRITE !!?50,"SECTION I - GENERAL INFORMATION"
+3 WRITE ?131,$CHAR(13)
if EALNE("ULC")="-"
WRITE !
WRITE EALNE("UL")
+4 WRITE !?18,"Federal law provides criminal penalties, including a fine and/or imprisonment for up to 5 years,"
+5 WRITE !?20,"for concealing a material fact or making a materially false statement. (See 18 U.S.C. 1001)"
+6 WRITE ?131,$CHAR(13)
if EALNE("ULC")="-"
WRITE !
WRITE EALNE("UL")
+7 ;
+8 WRITE !,"1. VETERAN'S NAME (Last, First, Middle Name)",?50,"|2. OTHER NAMES USED",?87,"|3. MOTHER'S MAIDEN NAME",?121,"|4. GENDER"
+9 WRITE !?3,@EASD@(2),?50,"| ",@EASD@(3),?87,"| ",@EASD@("3A"),?121,"| ",@EASD@(4)
+10 WRITE ?131,$CHAR(13)
if EALNE("ULC")="-"
WRITE !
WRITE EALNE("UL")
+11 ;
+12 WRITE !,"5. ARE YOU SPANISH, HISPANIC,",?32,"|6. WHAT IS YOUR RACE? ",@EASD@("4B"),"AMERICAN INDIAN OR ALASKA NATIVE"
+13 WRITE ?103,@EASD@("4C"),"BLACK OR AFRICAN AMERICAN"
+14 WRITE !?3,"OR LATINO? ",@EASD@("4A"),?32,"|",?57,@EASD@("4E"),"ASIAN"
+15 WRITE ?73,@EASD@("4F"),"WHITE",?87,@EASD@("4D"),"NATIVE HAWAIIAN OR OTHER PACIFIC ISLANDER"
+16 WRITE ?131,$CHAR(13)
if EALNE("ULC")="-"
WRITE !
WRITE EALNE("UL")
+17 ;
+18 WRITE !,"7. SOCIAL SECURITY NUMBER",?32,"|8. VA CLAIM NUMBER",?87,"|9. DATE OF BIRTH (mm/dd/yyyy)"
+19 WRITE !?3,@EASD@(5),?32,"| ",@EASD@(6),?87,"| ",@EASD@(7)
+20 WRITE ?131,$CHAR(13)
if EALNE("ULC")="-"
WRITE !
WRITE EALNE("UL")
+21 ;
+22 WRITE !,"9A. PLACE OF BIRTH (City & State)",?87,"|10. RELIGION"
+23 WRITE !?4,@EASD@("8A"),?87,"| ",@EASD@(8)
+24 WRITE ?131,$CHAR(13)
if EALNE("ULC")="-"
WRITE !
WRITE EALNE("UL")
+25 ;
+26 ;EAS*1.0*70
+27 ;Use domestic address field labels
IF $GET(@EASD@("9H"))="UNITED STATES"
Begin DoDot:1
+28 WRITE !,"11. PERMANENT ADDRESS (Street)",?41,"|11A. CITY",?64,"|11B. STATE",?107,"|11C. ZIP CODE (9 digits)"
+29 WRITE !?4,@EASD@("9A"),?41,"| ",@EASD@("9B"),?64,"| ",@EASD@("9C"),?107,"| ",@EASD@("9D")
+30 WRITE ?131,$CHAR(13)
if EALNE("ULC")="-"
WRITE !
WRITE EALNE("UL")
+31 ;
+32 WRITE !,"11D. COUNTY",?35,"|11E. HOME TELEPHONE NUMBER (Include area code) |11F. E-MAIL ADDRESS"
+33 WRITE !?5,@EASD@("9E"),?35,"| ",@EASD@(10),?84,"| ",@EASD@("11A")
End DoDot:1
IF 1
+34 ;
+35 ;Use foreign address field labels
IF '$TEST
Begin DoDot:1
+36 WRITE !,"11. PERMANENT ADDRESS (Street)",?41,"|11A. CITY",?64,"|11B. PROVINCE",?107,"|11C. POSTAL CODE"
+37 WRITE !?4,@EASD@("9A"),?41,"| ",@EASD@("9B"),?64,"| ",@EASD@("9F"),?107,"| ",@EASD@("9G")
+38 WRITE ?131,$CHAR(13)
if EALNE("ULC")="-"
WRITE !
WRITE EALNE("UL")
+39 ;
+40 WRITE !,"11D. COUNTRY",?35,"|11E. HOME TELEPHONE NUMBER (Include area code) |11F. E-MAIL ADDRESS"
+41 WRITE !?5,@EASD@("9H"),?35,"| ",@EASD@(10),?84,"| ",@EASD@("11A")
End DoDot:1
+42 ;
+43 WRITE ?131,$CHAR(13)
if EALNE("ULC")="-"
WRITE !
WRITE EALNE("UL")
+44 ;
+45 WRITE !,"11G. CELLULAR TELEPHONE NUMBER (Include area code)",?66,"|12. TYPE OF BENEFIT(S) APPLYING FOR"
+46 WRITE !?5,@EASD@("11G"),?66,"| ",@EASD@("1A")
+47 WRITE ?131,$CHAR(13)
if EALNE("ULC")="-"
WRITE !
WRITE EALNE("UL")
+48 ;
+49 WRITE !,"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"
+50 WRITE !?4,"DO YOU PREFER? ",@EASD@("1B"),?50,"| BECOMES AVAILABLE? ",@EASD@("11B")
+51 IF @EASD@("11B")="NO"
WRITE " I am only enrolling in case I need care in the future."
+52 WRITE ?131,$CHAR(13)
if EALNE("ULC")="-"
WRITE !
WRITE EALNE("UL")
+53 ;
+54 WRITE !,"15. CURRENT MARITAL STATUS ",@EASD@(12)
+55 WRITE ?131,$CHAR(13)
if EALNE("ULC")="-"
WRITE !
WRITE EALNE("UL")
+56 ;
+57 WRITE !,"16. NAME, ADDRESS AND RELATIONSHIP OF NEXT OF KIN",?83,"|16A. NEXT OF KIN'S HOME TELEPHONE NUMBER"
+58 WRITE !?4,$PIECE(@EASD@("19A"),U)," - ",$PIECE(@EASD@("19A"),U,4),?83,"| (Include area code) ",@EASD@("19B")
+59 WRITE ?131,$CHAR(13)
if EALNE("ULC")="-"
WRITE !
FOR X=1:1:84
WRITE " "
+60 WRITE $EXTRACT(EALNE("UL"),1,48)
+61 WRITE !?4,$PIECE(@EASD@("19A"),U,2),?83,"|16B. NEXT OF KIN'S WORK TELEPHONE NUMBER"
+62 WRITE !?4,$PIECE(@EASD@("19A"),U,3),?83,"| (Include area code) ",@EASD@("19C")
+63 WRITE ?131,$CHAR(13)
if EALNE("ULC")="-"
WRITE !
WRITE EALNE("UL")
+64 ;
+65 WRITE !,"17. NAME, ADDRESS AND RELATIONSHIP OF EMERGENCY CONTACT",?83,"|17A. EMERGENCY CONTACT'S HOME TELEPHONE NUMBER"
+66 WRITE !?4,$PIECE(@EASD@("20A"),U)," - ",$PIECE(@EASD@("20A"),U,4),?83,"| (Include area code) ",@EASD@("20B")
+67 WRITE ?131,$CHAR(13)
if EALNE("ULC")="-"
WRITE !
FOR X=1:1:84
WRITE " "
+68 WRITE $EXTRACT(EALNE("UL"),1,48)
+69 WRITE !?4,$PIECE(@EASD@("20A"),U,2),?83,"|17B. EMERGENCY CONTACT'S WORK TELEPHONE NUMBER"
+70 WRITE !?4,$PIECE(@EASD@("20A"),U,3),?83,"| (Include area code) ",@EASD@("20C")
+71 WRITE ?131,$CHAR(13)
if EALNE("ULC")="-"
WRITE !
WRITE EALNE("UL")
+72 ;
II ; Print SECTION II - INSURANCE INFORMATION
+1 ;
+2 WRITE !!?25,"SECTION II - INSURANCE INFORMATION (Use Separate Sheet for Additional Insurance)"
+3 WRITE ?131,$CHAR(13)
if EALNE("ULC")="-"
WRITE !
WRITE EALNE("UL")
+4 ;
+5 WRITE !,"1. HEALTH INSURANCE COMPANY NAME, ADDRESS AND TELEPHONE NUMBER"
+6 WRITE " (include coverage through spouse or other person)"
+7 WRITE !," ",@EASD@("17A"),?50,@EASD@("17J")
+8 IF @EASD@("17E")'=""
WRITE !," ",@EASD@("17E"),", ",@EASD@("17F"),", ",@EASD@("17G")," ",@EASD@("17H")
+9 WRITE ?131,$CHAR(13)
if EALNE("ULC")="-"
WRITE !
WRITE EALNE("UL")
+10 ;
+11 WRITE !,"2. NAME OF POLICY HOLDER",?33,"|3. POLICY NUMBER",?57,"|4. GROUP CODE"
+12 WRITE ?78,"|5. ARE YOU ELIG. FOR MEDICAID?",?112,"|5A. EFFECTIVE DATE"
+13 WRITE !?3,@EASD@("17B"),?33,"| ",@EASD@("17C"),?57,"| ",@EASD@("17D")
+14 WRITE ?78,"| ",@EASD@("14J"),?112,"|"
+15 WRITE ?131,$CHAR(13)
if EALNE("ULC")="-"
WRITE !
WRITE EALNE("UL")
+16 ;
+17 WRITE !,"6. ARE YOU ENROLLED IN MEDICARE HOSPITAL INSURANCE PART A? ",@EASD@("14K"),?75,"|6A. EFFECTIVE DATE (mm/dd/yyyy) ",@EASD@("14K1")
+18 WRITE ?131,$CHAR(13)
if EALNE("ULC")="-"
WRITE !
WRITE EALNE("UL")
+19 ;
+20 WRITE !,"7. ARE YOU ENROLLED IN MEDICARE HOSPITAL INSURANCE PART B? ",@EASD@("14L"),?75,"|7A. EFFECTIVE DATE (mm/dd/yyyy) ",@EASD@("14L1")
+21 WRITE ?131,$CHAR(13)
if EALNE("ULC")="-"
WRITE !
WRITE EALNE("UL")
+22 ;
+23 WRITE !,"8. NAME EXACTLY AS IT APPEARS ON YOUR MEDICARE CARD",?70,"|9. MEDICARE CLAIM NUMBER"
+24 WRITE !?3,@EASD@("14N"),?70,"| ",@EASD@("14M")
+25 WRITE ?131,$CHAR(13)
if EALNE("ULC")="-"
WRITE !
WRITE EALNE("UL")
+26 ;
+27 QUIT
