- EASEZP64 ; ALB/AMA,LBD - Print 1010EZ, Version 6 or greater, Cont. ; 10/29/12 12:30pm
- ;;1.0;ENROLLMENT APPLICATION SYSTEM;**60,57,70,107**;Mar 15, 2001;Build 32
- ;
- ;This routine carved from EASEZPF3; if the version # of the 1010EZ
- ;application is 6.0 or greater, then this routine will be executed.
- ;
- ;EAS*1.0*107 - The new version of the 10-10EZ form has all these
- ;sections as a continuation of page 3. There is no longer a page 4.
- ;
- EN(EALNE,EAINFO,EASDG) ;Entry point to print Page 3, called from EN^EASEZP6F
- ; Input
- ; EALNE - Array of line formats for output
- ; EAINFO - Application Data array, see SETUP^EASEZPF
- ; EASDG - Flag variable to signify request to print from DG options
- ;
- N EASIGN,EASD
- ;
- I $$GET1^DIQ(712,EAINFO("EASAPP")_",",4)]"" D
- . S EASIGN=$$GET1^DIQ(712,EAINFO("EASAPP")_",",4.1)
- S EASIGN=$G(EASIGN)
- ;
- S EASD=$NA(^TMP("EASEZ",$J,2))
- ;
- D NET
- D PAP
- D CON
- D AOB
- D FT^EASEZP6F(.EALNE,.EAINFO)
- ;
- Q
- ;
- NET ; Print SECTION IX - PREVIOUS CALENDAR YEAR NET WORTH
- ;
- I $G(EASDG),+@EASD@(999) W !!?2,"SECTION IX - PREVIOUS CALENDAR YEAR NET WORTH (INCOME YEAR: ",@EASD@(999),") (Use a separate sheet for additional dependents)"
- E W !!?38,"SECTION IX - PREVIOUS CALENDAR YEAR NET WORTH (Use a separate sheet for additional dependents)"
- W ?131,$C(13) W:EALNE("ULC")="-" ! W EALNE("UL")
- ;
- W !?78,"|",?84,"VETERAN",?96,"|",?102,"SPOUSE",?114,"|",?120,"CHILD 1"
- W ?131,$C(13) W:EALNE("ULC")="-" ! W EALNE("UL")
- ;
- W !,"1. CASH, AMOUNT IN BANK ACCOUNTS (e.g., checking and savings accounts,",?78,"| $ ",$P(@EASD@("2E1"),U),?96,"| $ ",$P(@EASD@("2E1"),U,2),?114,"| $ ",$P(@EASD@("2E1"),U,3)
- W !,"certificates of deposit, individual retirement accounts, stocks and bonds)",?78,"|",?96,"|",?114,"|"
- W ?131,$C(13) W:EALNE("ULC")="-" ! W EALNE("UL")
- ;
- W !,"2. MARKET VALUE OF LAND AND BUILDINGS MINUS MORTGAGES AND LIENS (e.g., second",?78,"| $ ",$P(@EASD@("2E2"),U),?96,"| $ ",$P(@EASD@("2E2"),U,2),?114,"| $ ",$P(@EASD@("2E2"),U,3)
- W !,"homes and non-income-producing property. Do not count your primary home.)",?78,"|",?96,"|",?114,"|"
- W ?131,$C(13) W:EALNE("ULC")="-" ! W EALNE("UL")
- ;
- W !,"3. VALUE OF OTHER PROPERTY OR ASSETS (e.g., art, rare coins, collectibles)",?78,"| $ ",$P(@EASD@("2E3"),U),?96,"| $ ",$P(@EASD@("2E3"),U,2),?114,"| $ ",$P(@EASD@("2E3"),U,3)
- W !,"MINUS THE AMOUNT YOU OWE ON THESE ITEMS. INCLUDE VALUE OF FARM, RANCH, OR",?78,"|",?96,"|",?114,"|"
- W !,"BUSINESS ASSETS. Exclude household effects and family vehicles.",?78,"|",?96,"|",?114,"|"
- W ?131,$C(13) W:EALNE("ULC")="-" ! W EALNE("UL")
- Q
- ;
- ;
- PAP ; Print SECTION X - PAPERWORK AND PRIVACY ACT INFORMATION
- ;
- W !!?34,"SECTION X - PAPERWORK REDUCTION ACT AND PRIVACY ACT INFORMATION"
- W ?131,$C(13) W:EALNE("ULC")="-" ! W EALNE("UL")
- ;
- W !,"The Paperwork Reduction Act of 1995 requires us to notify you that this information collection is in accordance with the"
- W !,"clearance requirements of section 3507 of the Paperwork Reduction Act of 1995. We may not conduct or sponsor, and you are not"
- W !,"required to respond to, a collection of information unless it displays a valid OMB number. We anticipate that the time expended by"
- W !,"all individuals who must complete this form will average 45 minutes. This includes the time it will take to read instructions,"
- W !,"gather the necessary facts and fill out the form."
- W !,"Privacy Act Information: VA is asking you to provide the information on this form under 38 U.S.C., sections 1705, 1710, 1712,"
- W !,"and 1722 in order for VA to determine your eligibility for medical benefits. Information you supply may be verified through a"
- W !,"computer-matching program. VA may disclose the information that you put on the form as permitted by law. VA may make a ""routine"
- W !,"use"" disclosure of the information as outlined in the Privacy Act systems of records notices and in accordance with the VHA Notice"
- W !,"of Privacy Practices. Providing the requested information is voluntary, but if any or all of the requested information is not"
- W !,"provided, it may delay or result in denial of your request for health care benefits. Failure to furnish the information will not"
- W !,"have any effect on any other benefits to which you may be entitled. If you provide VA your Social Security Number, VA will use it"
- W !,"to administer your VA benefits. VA may also use this information to identify Veterans and persons claiming or receiving VA"
- W !,"benefits and their records, and for other purposes authorized or required by law."
- W ?131,$C(13) W:EALNE("ULC")="-" ! W EALNE("UL")
- Q
- CON ; Print SECTION XI - CONSENT TO COPAYS
- ;
- W !!?49,"SECTION XI - CONSENT TO COPAYS"
- W ?131,$C(13) W:EALNE("ULC")="-" ! W EALNE("UL")
- ;
- W !,"By signing this application you are agreeing to pay the applicable VA copays for treatment or services of your NSC conditions as"
- W !,"required by law."
- W ?131,$C(13) W:EALNE("ULC")="-" ! W EALNE("UL")
- Q
- ;
- AOB ; Print SECTION XII - ASSIGNMENT OF BENEFITS
- ;
- W !!?48,"SECTION XII - ASSIGNMENT OF BENEFITS"
- W ?131,$C(13) W:EALNE("ULC")="-" ! W EALNE("UL")
- ;
- W !,"I understand that pursuant to 38 U.S.C. section 1729 and 42 U.S.C. 2651, the Department of Veterans Affairs (VA) is authorized to"
- W !,"recover or collect from my health plan (HP) or any other legally responsible third party for the reasonable charges of "
- W !,"nonservice-connected VA medical care or services furnished or provided to me. I hereby authorize payment directly to VA from any"
- W !,"HP under which I am covered (including coverage provided under my spouse's HP) that is responsible for payment of the charges for"
- W !,"my medical care, including benefits otherwise payable to me or my spouse. Furthermore, I hereby assign to the VA any claim I may"
- W !,"have against any person or entity who is or may be legally responsible for the payment of the cost of medical services provided to"
- W !,"me by the VA. I understand that this assignment shall not limit or prejudice my right to recover for my own benefit any amount in"
- W !,"excess of the cost of medical services provided to me by the VA or any other amount to which I may be entitled. I hereby appoint"
- W !,"the Attorney General of the United States and the Secretary of Veterans' Affairs and their designees as my Attorneys-in-fact to"
- W !,"take all necessary and appropriate actions in order to recover and receive all or part of the amount herein assigned. I hereby"
- W !,"authorize the VA to disclose, to my attorney and to any third party or administrative agency who may be responsible for payment of"
- W !,"the cost of medical services provided to me, information from my medical records as necessary to verify my claim. Further, I hereby"
- W !,"authorize any such third party or administrative agency to disclose to the VA any information regarding my claim."
- W ?131,$C(13) W:EALNE("ULC")="-" ! W EALNE("UL")
- ;
- W !!?6,"ALL APPLICANTS MUST SIGN AND DATE THIS FORM. REFER TO INSTRUCTIONS WHICH DEFINE WHO CAN SIGN ON BEHALF OF THE VETERAN.",!
- W ?131,$C(13) W:EALNE("ULC")="-" ! W EALNE("UL")
- ;
- W !,"SIGNATURE OF APPLICANT",?90,"| DATE"
- I $G(EASIGN)]"" W !,"SIGNATURE OF APPLICANT OR APPLICANT'S REPRESENTATIVE HAS BEEN VERIFIED",?90,"| ",EASIGN,!?90,"|"
- E W !?90,"|",!?90,"|"
- W ?131,$C(13) W:EALNE("ULC")="-" ! W EALNE("UL")
- Q
- --- Routine Detail --- with STRUCTURED ROUTINE LISTING ---[H[J[2J[HEASEZP64 7476 printed Jan 18, 2025@02:55:58 Page 2
- EASEZP64 ; ALB/AMA,LBD - Print 1010EZ, Version 6 or greater, Cont. ; 10/29/12 12:30pm
- +1 ;;1.0;ENROLLMENT APPLICATION SYSTEM;**60,57,70,107**;Mar 15, 2001;Build 32
- +2 ;
- +3 ;This routine carved from EASEZPF3; if the version # of the 1010EZ
- +4 ;application is 6.0 or greater, then this routine will be executed.
- +5 ;
- +6 ;EAS*1.0*107 - The new version of the 10-10EZ form has all these
- +7 ;sections as a continuation of page 3. There is no longer a page 4.
- +8 ;
- EN(EALNE,EAINFO,EASDG) ;Entry point to print Page 3, called from EN^EASEZP6F
- +1 ; Input
- +2 ; EALNE - Array of line formats for output
- +3 ; EAINFO - Application Data array, see SETUP^EASEZPF
- +4 ; EASDG - Flag variable to signify request to print from DG options
- +5 ;
- +6 NEW EASIGN,EASD
- +7 ;
- +8 IF $$GET1^DIQ(712,EAINFO("EASAPP")_",",4)]""
- Begin DoDot:1
- +9 SET EASIGN=$$GET1^DIQ(712,EAINFO("EASAPP")_",",4.1)
- End DoDot:1
- +10 SET EASIGN=$GET(EASIGN)
- +11 ;
- +12 SET EASD=$NAME(^TMP("EASEZ",$JOB,2))
- +13 ;
- +14 DO NET
- +15 DO PAP
- +16 DO CON
- +17 DO AOB
- +18 DO FT^EASEZP6F(.EALNE,.EAINFO)
- +19 ;
- +20 QUIT
- +21 ;
- NET ; Print SECTION IX - PREVIOUS CALENDAR YEAR NET WORTH
- +1 ;
- +2 IF $GET(EASDG)
- IF +@EASD@(999)
- WRITE !!?2,"SECTION IX - PREVIOUS CALENDAR YEAR NET WORTH (INCOME YEAR: ",@EASD@(999),") (Use a separate sheet for additional dependents)"
- +3 IF '$TEST
- WRITE !!?38,"SECTION IX - PREVIOUS CALENDAR YEAR NET WORTH (Use a separate sheet for additional dependents)"
- +4 WRITE ?131,$CHAR(13)
- if EALNE("ULC")="-"
- WRITE !
- WRITE EALNE("UL")
- +5 ;
- +6 WRITE !?78,"|",?84,"VETERAN",?96,"|",?102,"SPOUSE",?114,"|",?120,"CHILD 1"
- +7 WRITE ?131,$CHAR(13)
- if EALNE("ULC")="-"
- WRITE !
- WRITE EALNE("UL")
- +8 ;
- +9 WRITE !,"1. CASH, AMOUNT IN BANK ACCOUNTS (e.g., checking and savings accounts,",?78,"| $ ",$PIECE(@EASD@("2E1"),U),?96,"| $ ",$PIECE(@EASD@("2E1"),U,2),?114,"| $ ",$PIECE(@EASD@("2E1"),U,3)
- +10 WRITE !,"certificates of deposit, individual retirement accounts, stocks and bonds)",?78,"|",?96,"|",?114,"|"
- +11 WRITE ?131,$CHAR(13)
- if EALNE("ULC")="-"
- WRITE !
- WRITE EALNE("UL")
- +12 ;
- +13 WRITE !,"2. MARKET VALUE OF LAND AND BUILDINGS MINUS MORTGAGES AND LIENS (e.g., second",?78,"| $ ",$PIECE(@EASD@("2E2"),U),?96,"| $ ",$PIECE(@EASD@("2E2"),U,2),?114,"| $ ",$PIECE(@EASD@("2E2"),U,3)
- +14 WRITE !,"homes and non-income-producing property. Do not count your primary home.)",?78,"|",?96,"|",?114,"|"
- +15 WRITE ?131,$CHAR(13)
- if EALNE("ULC")="-"
- WRITE !
- WRITE EALNE("UL")
- +16 ;
- +17 WRITE !,"3. VALUE OF OTHER PROPERTY OR ASSETS (e.g., art, rare coins, collectibles)",?78,"| $ ",$PIECE(@EASD@("2E3"),U),?96,"| $ ",$PIECE(@EASD@("2E3"),U,2),?114,"| $ ",$PIECE(@EASD@("2E3"),U,3)
- +18 WRITE !,"MINUS THE AMOUNT YOU OWE ON THESE ITEMS. INCLUDE VALUE OF FARM, RANCH, OR",?78,"|",?96,"|",?114,"|"
- +19 WRITE !,"BUSINESS ASSETS. Exclude household effects and family vehicles.",?78,"|",?96,"|",?114,"|"
- +20 WRITE ?131,$CHAR(13)
- if EALNE("ULC")="-"
- WRITE !
- WRITE EALNE("UL")
- +21 QUIT
- +22 ;
- +23 ;
- PAP ; Print SECTION X - PAPERWORK AND PRIVACY ACT INFORMATION
- +1 ;
- +2 WRITE !!?34,"SECTION X - PAPERWORK REDUCTION ACT AND PRIVACY ACT INFORMATION"
- +3 WRITE ?131,$CHAR(13)
- if EALNE("ULC")="-"
- WRITE !
- WRITE EALNE("UL")
- +4 ;
- +5 WRITE !,"The Paperwork Reduction Act of 1995 requires us to notify you that this information collection is in accordance with the"
- +6 WRITE !,"clearance requirements of section 3507 of the Paperwork Reduction Act of 1995. We may not conduct or sponsor, and you are not"
- +7 WRITE !,"required to respond to, a collection of information unless it displays a valid OMB number. We anticipate that the time expended by"
- +8 WRITE !,"all individuals who must complete this form will average 45 minutes. This includes the time it will take to read instructions,"
- +9 WRITE !,"gather the necessary facts and fill out the form."
- +10 WRITE !,"Privacy Act Information: VA is asking you to provide the information on this form under 38 U.S.C., sections 1705, 1710, 1712,"
- +11 WRITE !,"and 1722 in order for VA to determine your eligibility for medical benefits. Information you supply may be verified through a"
- +12 WRITE !,"computer-matching program. VA may disclose the information that you put on the form as permitted by law. VA may make a ""routine"
- +13 WRITE !,"use"" disclosure of the information as outlined in the Privacy Act systems of records notices and in accordance with the VHA Notice"
- +14 WRITE !,"of Privacy Practices. Providing the requested information is voluntary, but if any or all of the requested information is not"
- +15 WRITE !,"provided, it may delay or result in denial of your request for health care benefits. Failure to furnish the information will not"
- +16 WRITE !,"have any effect on any other benefits to which you may be entitled. If you provide VA your Social Security Number, VA will use it"
- +17 WRITE !,"to administer your VA benefits. VA may also use this information to identify Veterans and persons claiming or receiving VA"
- +18 WRITE !,"benefits and their records, and for other purposes authorized or required by law."
- +19 WRITE ?131,$CHAR(13)
- if EALNE("ULC")="-"
- WRITE !
- WRITE EALNE("UL")
- +20 QUIT
- CON ; Print SECTION XI - CONSENT TO COPAYS
- +1 ;
- +2 WRITE !!?49,"SECTION XI - CONSENT TO COPAYS"
- +3 WRITE ?131,$CHAR(13)
- if EALNE("ULC")="-"
- WRITE !
- WRITE EALNE("UL")
- +4 ;
- +5 WRITE !,"By signing this application you are agreeing to pay the applicable VA copays for treatment or services of your NSC conditions as"
- +6 WRITE !,"required by law."
- +7 WRITE ?131,$CHAR(13)
- if EALNE("ULC")="-"
- WRITE !
- WRITE EALNE("UL")
- +8 QUIT
- +9 ;
- AOB ; Print SECTION XII - ASSIGNMENT OF BENEFITS
- +1 ;
- +2 WRITE !!?48,"SECTION XII - ASSIGNMENT OF BENEFITS"
- +3 WRITE ?131,$CHAR(13)
- if EALNE("ULC")="-"
- WRITE !
- WRITE EALNE("UL")
- +4 ;
- +5 WRITE !,"I understand that pursuant to 38 U.S.C. section 1729 and 42 U.S.C. 2651, the Department of Veterans Affairs (VA) is authorized to"
- +6 WRITE !,"recover or collect from my health plan (HP) or any other legally responsible third party for the reasonable charges of "
- +7 WRITE !,"nonservice-connected VA medical care or services furnished or provided to me. I hereby authorize payment directly to VA from any"
- +8 WRITE !,"HP under which I am covered (including coverage provided under my spouse's HP) that is responsible for payment of the charges for"
- +9 WRITE !,"my medical care, including benefits otherwise payable to me or my spouse. Furthermore, I hereby assign to the VA any claim I may"
- +10 WRITE !,"have against any person or entity who is or may be legally responsible for the payment of the cost of medical services provided to"
- +11 WRITE !,"me by the VA. I understand that this assignment shall not limit or prejudice my right to recover for my own benefit any amount in"
- +12 WRITE !,"excess of the cost of medical services provided to me by the VA or any other amount to which I may be entitled. I hereby appoint"
- +13 WRITE !,"the Attorney General of the United States and the Secretary of Veterans' Affairs and their designees as my Attorneys-in-fact to"
- +14 WRITE !,"take all necessary and appropriate actions in order to recover and receive all or part of the amount herein assigned. I hereby"
- +15 WRITE !,"authorize the VA to disclose, to my attorney and to any third party or administrative agency who may be responsible for payment of"
- +16 WRITE !,"the cost of medical services provided to me, information from my medical records as necessary to verify my claim. Further, I hereby"
- +17 WRITE !,"authorize any such third party or administrative agency to disclose to the VA any information regarding my claim."
- +18 WRITE ?131,$CHAR(13)
- if EALNE("ULC")="-"
- WRITE !
- WRITE EALNE("UL")
- +19 ;
- +20 WRITE !!?6,"ALL APPLICANTS MUST SIGN AND DATE THIS FORM. REFER TO INSTRUCTIONS WHICH DEFINE WHO CAN SIGN ON BEHALF OF THE VETERAN.",!
- +21 WRITE ?131,$CHAR(13)
- if EALNE("ULC")="-"
- WRITE !
- WRITE EALNE("UL")
- +22 ;
- +23 WRITE !,"SIGNATURE OF APPLICANT",?90,"| DATE"
- +24 IF $GET(EASIGN)]""
- WRITE !,"SIGNATURE OF APPLICANT OR APPLICANT'S REPRESENTATIVE HAS BEEN VERIFIED",?90,"| ",EASIGN,!?90,"|"
- +25 IF '$TEST
- WRITE !?90,"|",!?90,"|"
- +26 WRITE ?131,$CHAR(13)
- if EALNE("ULC")="-"
- WRITE !
- WRITE EALNE("UL")
- +27 QUIT