EASEZPF1 ;ALB/SCK - Print 1010EZ Cont. ; 10/19/2000
;;1.0;ENROLLMENT APPLICATION SYSTEM;;Mar 15, 2001
;
EN(EALNE,EAINFO) ; Main entry point for VA 10-10EZ page 1
N X,EASD
;
S EASD="^TMP(""EASEZ"",$J,1)"
D HDRMAIN^EASEZPF(.EALNE)
D DEM
D EXP
D EMP
D INS
D NOK
;
D FT^EASEZPF(.EALNE,.EAINFO)
S EAINFO("VET")=@EASD@(2),EAINFO("SSN")=@EASD@(5)
Q
;
DEM ; Print VA 10-10 Section I, Demographic information
;
W !,"1A. Type of Benefits Applied For: ",@EASD@("1A")
W ?131,$C(13) W:EALNE("ULC")="-" ! W EALNE("UL")
;
W !,"1B. If Applying For Health Services, Which VA Medical Center or Outpatient Clinic Do You Prefer "
W !?5,@EASD@("1B")
W ?131,$C(13) W:EALNE("ULC")="-" ! W EALNE("UL")
;
W !,"2. Veteran's Name",?60,"|3. Other Names Used",?110,"|4. Gender"
W !?3,@EASD@(2),?60,"| ",@EASD@(3),?110,"| ",@EASD@(4)
W ?131,$C(13) W:EALNE("ULC")="-" ! W EALNE("UL")
;
W !,"5. Social Security Number",?30,"|6. Claim Number",?60,"|7. Date of Birth",?95,"|8. Religion"
W !?4,@EASD@(5),?30,"| ",@EASD@(6),?60,"| ",@EASD@(7),?95,"| ",@EASD@(8)
W ?131,$C(13) W:EALNE("ULC")="-" ! W EALNE("UL")
;
W !,"9A. Current Mailing Address",?60,"|9B. City",?95,"|9C. State",?110,"|9D. Zip"
W !?4,@EASD@("9A"),?60,"| ",@EASD@("9B"),?95,"| ",@EASD@("9C"),?110,"| ",@EASD@("9D")
W ?131,$C(13) W:EALNE("ULC")="-" ! W EALNE("UL")
;
W !,"9E. County ",?40,"|10. Home Telephone Number ",?85,"|11. Work Telephone Number "
W !?4,@EASD@("9E"),?40,"| ",@EASD@(10),?85,"| ",@EASD@(11)
W ?131,$C(13) W:EALNE("ULC")="-" ! W EALNE("UL")
;
W !,"12. Current Marital Status: ",@EASD@(12)
W ?131,$C(13) W:EALNE("ULC")="-" ! W EALNE("UL")
;
W !,"13A. Last Branch of Service",?28,"|13B. Last Entry Date",?52,"|13C.Last Discharge Date",?78,"|13D. Discharge Type",?100,"|13E. Military Service Number"
W !?4,@EASD@("13A"),?28,"| ",@EASD@("13B"),?52,"| ",@EASD@("13C"),?78,"| ",@EASD@("13D"),?100,"| ",@EASD@("13E")
Q
;
EXP ; Print VA 10-10EZ Section I, Questions
;
W !,EALNE("D"),!?2,"14. Answer Yes or No for the Following Questions"
W ?131,$C(13) W:EALNE("ULC")="-" ! W EALNE("UL")
;
W !?2,"A1.",?6,"Are You a Purple Heart Award Recipient ",?58,@EASD@("14A1"),?65,"|"
W ?131,$C(13) W:EALNE("ULC")="-" ! W EALNE("UL")
;
W !?2,"A2.",?6,"Are You a Former Prisoner of War ",?58,@EASD@("14A2"),?65,"|H.",?70,"Do You Have a Military Dental Injury",?126,@EASD@("14H")
W ?131,$C(13) W:EALNE("ULC")="-" ! W EALNE("UL")
;
W !?2,"B.",?6,"Do You Have a VA Service Connected Rating ",?58,@EASD@("14B"),?65,"|I.",?70,"Do You Have a Spinal Cord Injury ",?126,@EASD@("14I")
W ?131,$C(13) W:EALNE("ULC")="-" ! W EALNE("UL")
;
W !?2,"B1.",?6,"If Yes, What is Your Rated Percentage ",?58,@EASD@("14B1"),?63,"% |J.",?70,"Are You Eligible for MEDICAID",?126,@EASD@("14J")
W ?131,$C(13) W:EALNE("ULC")="-" ! W EALNE("UL")
;
W !?2,"C.",?6,"Are You Receiving a VA Pension: ",?58,@EASD@("14C"),?65,"|K.",?70,"Are You Enrolled in MEDICARE Hospital Insurance Part A",?126,@EASD@("14K")
W ?131,$C(13) W:EALNE("ULC")="-" ! W EALNE("UL")
;
W !?2,"D.",?6,"Are You Retired From The Military: ",?58,@EASD@("14D"),?65,"|K1.",?70,"Effective Date",?110,@EASD@("14K1")
W ?131,$C(13) W:EALNE("ULC")="-" ! W EALNE("UL")
;
W !?2,"D1.",?6,"Was Your Retirement The Result Of a Disability: ",?58,@EASD@("14D1"),?65,"|L.",?70,"Are You Enrolled in MEDICARE Hospital Insurance Part B",?126,@EASD@("14L")
W ?131,$C(13) W:EALNE("ULC")="-" ! W EALNE("UL")
;
W !?2,"D2.",?6,"Were You Regularly Retired (20+yrs.)",?58,@EASD@("14D2"),?65,"|L1.",?70,"Effective Date",?110,@EASD@("14L1")
W ?131,$C(13) W:EALNE("ULC")="-" ! W EALNE("UL")
;
W !?2,"E.",?6,"Were You Exposed To Toxins In The Gulf War",?58,@EASD@("14E"),?65,"|M.",?70,"MEDICARE Claim Number",?110,@EASD@("14M")
W ?131,$C(13) W:EALNE("ULC")="-" ! W EALNE("UL")
;
W !?2,"F.",?6,"Were You Exposed To Agent Orange",?58,@EASD@("14F"),?65,"|N.",?70,"Name Exactly As It Appears On Your MEDICARE Card"
W ?131,$C(13) W:EALNE("ULC")="-" ! W $E(EALNE("UL"),1,65)
;
W !?2,"G.",?6,"Were You Exposed to Radiation",?58,@EASD@("14G"),?65,"| ",@EASD@("14N")
Q
;
EMP ;
W !,EALNE("D")
W !,"15A. Veteran's Employment Status ",$P(@EASD@("15A"),U),?58,"| 15B. Company Name, Address, Telephone"
W !?5,"Date of Retirement: ",$P(@EASD@("15A"),U,2),?58,"| ",$P(@EASD@("15B"),U)," ",$P(@EASD@("15B"),U,3)
W !?7,"(If employed or retired, complete 15B)",?58,"| ",$P(@EASD@("15B"),U,2)
W ?131,$C(13) W:EALNE("ULC")="-" ! W EALNE("UL")
;
W !,"16A. Spouse's Employment Status ",$P(@EASD@("16A"),U),?58,"| 16B. Company Name, Address, Telephone"
W !?5,"Date of Retirement: ",$P(@EASD@("16A"),U,2),?58,"| ",$P(@EASD@("16B"),U)," ",$P(@EASD@("16B"),U,3)
W !?7,"(If employed or retired, complete 16B)",?58,"| ",$P(@EASD@("16B"),U,2)
W ?131,$C(13) W:EALNE("ULC")="-" ! W EALNE("UL")
Q
;
INS ;
W !,"17. Does The Veteran Have Health Insurance",?65,"|18. Does The Spouse Have Health Insurance"
W !," (Other Than Medicare) ",@EASD@(17),?65,"| (Other Than Medicare) ",@EASD@(18)
W ?131,$C(13) W:EALNE("ULC")="-" ! W EALNE("UL")
;
W !,"17A. Veteran's Health Insurance Co.",?65,"|18A. Spouse's Health Insurance Co."
W !?1,@EASD@("17A"),?65,"| ",@EASD@("18A")
W !
W ?131,$C(13) W:EALNE("ULC")="-" ! W EALNE("UL")
;
W !,"17B. Name of Policy Holder ",@EASD@("17B"),?65,"|18B. Name of Policy Holder ",@EASD@("18B")
W ?131,$C(13) W:EALNE("ULC")="-" ! W EALNE("UL")
;
W !,"17C. Policy Number",?32,"|17D. Group Code",?65,"|18C. Policy Number",?98,"|18D. Group Code"
W !,@EASD@("17C"),?32,"| ",@EASD@("17D"),?65,"| ",@EASD@("18C"),?98,"| ",@EASD@("18D")
W ?131,$C(13) W:EALNE("ULC")="-" ! W EALNE("UL")
Q
;
NOK ;
W !,"19A. Name, Address and Relationship Of Next of Kin",?80,"|19B. Home Telephone ",@EASD@("19B")
W !?1,$P(@EASD@("19A"),U)," - ",$P(@EASD@("19A"),U,3),?80,"|19C. Work Telephone ",@EASD@("19C")
W !?1,$P(@EASD@("19A"),U,2),?80,"|"
W ?131,$C(13) W:EALNE("ULC")="-" ! W EALNE("UL")
;
W !,"20A. Name, Adress and Relationship Of Emergency Contact",?80,"|20B. Home Telephone ",@EASD@("20B")
W !?1,$P(@EASD@("20A"),U)," - ",$P(@EASD@("20A"),U,3),?80,"|20C. Work Telephone ",@EASD@("20C")
W !?1,$P(@EASD@("20A"),U,2),?80,"|"
W ?131,$C(13) W:EALNE("ULC")="-" ! W EALNE("UL")
;
W !,"21. I DESIGNATE THE FOLLOWING INDIVIDUAL TO RECEIVE POSSESSION OF ALL MY PERSONAL PROPERTY LEFT ON PREMISES UNDER VA CONTROL AFTER"
W !," MY DEPARTURE OR AT THE TIME OF MY DEATH. (This does not constitute a will or transfer of title.) ",@EASD@(21)
W ?131,$C(13) W:EALNE("ULC")="-" ! W EALNE("UL")
;
W !,"22A. Is Need For Care Due To On The Job Injury ",@EASD@("22A"),?65,"|22B. Is Need For Care Due To Accident ",@EASD@("22B")
Q
--- Routine Detail --- with STRUCTURED ROUTINE LISTING ---[H[J[2J[HEASEZPF1 6846 printed Oct 16, 2024@17:55:39 Page 2
EASEZPF1 ;ALB/SCK - Print 1010EZ Cont. ; 10/19/2000
+1 ;;1.0;ENROLLMENT APPLICATION SYSTEM;;Mar 15, 2001
+2 ;
EN(EALNE,EAINFO) ; Main entry point for VA 10-10EZ page 1
+1 NEW X,EASD
+2 ;
+3 SET EASD="^TMP(""EASEZ"",$J,1)"
+4 DO HDRMAIN^EASEZPF(.EALNE)
+5 DO DEM
+6 DO EXP
+7 DO EMP
+8 DO INS
+9 DO NOK
+10 ;
+11 DO FT^EASEZPF(.EALNE,.EAINFO)
+12 SET EAINFO("VET")=@EASD@(2)
SET EAINFO("SSN")=@EASD@(5)
+13 QUIT
+14 ;
DEM ; Print VA 10-10 Section I, Demographic information
+1 ;
+2 WRITE !,"1A. Type of Benefits Applied For: ",@EASD@("1A")
+3 WRITE ?131,$CHAR(13)
if EALNE("ULC")="-"
WRITE !
WRITE EALNE("UL")
+4 ;
+5 WRITE !,"1B. If Applying For Health Services, Which VA Medical Center or Outpatient Clinic Do You Prefer "
+6 WRITE !?5,@EASD@("1B")
+7 WRITE ?131,$CHAR(13)
if EALNE("ULC")="-"
WRITE !
WRITE EALNE("UL")
+8 ;
+9 WRITE !,"2. Veteran's Name",?60,"|3. Other Names Used",?110,"|4. Gender"
+10 WRITE !?3,@EASD@(2),?60,"| ",@EASD@(3),?110,"| ",@EASD@(4)
+11 WRITE ?131,$CHAR(13)
if EALNE("ULC")="-"
WRITE !
WRITE EALNE("UL")
+12 ;
+13 WRITE !,"5. Social Security Number",?30,"|6. Claim Number",?60,"|7. Date of Birth",?95,"|8. Religion"
+14 WRITE !?4,@EASD@(5),?30,"| ",@EASD@(6),?60,"| ",@EASD@(7),?95,"| ",@EASD@(8)
+15 WRITE ?131,$CHAR(13)
if EALNE("ULC")="-"
WRITE !
WRITE EALNE("UL")
+16 ;
+17 WRITE !,"9A. Current Mailing Address",?60,"|9B. City",?95,"|9C. State",?110,"|9D. Zip"
+18 WRITE !?4,@EASD@("9A"),?60,"| ",@EASD@("9B"),?95,"| ",@EASD@("9C"),?110,"| ",@EASD@("9D")
+19 WRITE ?131,$CHAR(13)
if EALNE("ULC")="-"
WRITE !
WRITE EALNE("UL")
+20 ;
+21 WRITE !,"9E. County ",?40,"|10. Home Telephone Number ",?85,"|11. Work Telephone Number "
+22 WRITE !?4,@EASD@("9E"),?40,"| ",@EASD@(10),?85,"| ",@EASD@(11)
+23 WRITE ?131,$CHAR(13)
if EALNE("ULC")="-"
WRITE !
WRITE EALNE("UL")
+24 ;
+25 WRITE !,"12. Current Marital Status: ",@EASD@(12)
+26 WRITE ?131,$CHAR(13)
if EALNE("ULC")="-"
WRITE !
WRITE EALNE("UL")
+27 ;
+28 WRITE !,"13A. Last Branch of Service",?28,"|13B. Last Entry Date",?52,"|13C.Last Discharge Date",?78,"|13D. Discharge Type",?100,"|13E. Military Service Number"
+29 WRITE !?4,@EASD@("13A"),?28,"| ",@EASD@("13B"),?52,"| ",@EASD@("13C"),?78,"| ",@EASD@("13D"),?100,"| ",@EASD@("13E")
+30 QUIT
+31 ;
EXP ; Print VA 10-10EZ Section I, Questions
+1 ;
+2 WRITE !,EALNE("D"),!?2,"14. Answer Yes or No for the Following Questions"
+3 WRITE ?131,$CHAR(13)
if EALNE("ULC")="-"
WRITE !
WRITE EALNE("UL")
+4 ;
+5 WRITE !?2,"A1.",?6,"Are You a Purple Heart Award Recipient ",?58,@EASD@("14A1"),?65,"|"
+6 WRITE ?131,$CHAR(13)
if EALNE("ULC")="-"
WRITE !
WRITE EALNE("UL")
+7 ;
+8 WRITE !?2,"A2.",?6,"Are You a Former Prisoner of War ",?58,@EASD@("14A2"),?65,"|H.",?70,"Do You Have a Military Dental Injury",?126,@EASD@("14H")
+9 WRITE ?131,$CHAR(13)
if EALNE("ULC")="-"
WRITE !
WRITE EALNE("UL")
+10 ;
+11 WRITE !?2,"B.",?6,"Do You Have a VA Service Connected Rating ",?58,@EASD@("14B"),?65,"|I.",?70,"Do You Have a Spinal Cord Injury ",?126,@EASD@("14I")
+12 WRITE ?131,$CHAR(13)
if EALNE("ULC")="-"
WRITE !
WRITE EALNE("UL")
+13 ;
+14 WRITE !?2,"B1.",?6,"If Yes, What is Your Rated Percentage ",?58,@EASD@("14B1"),?63,"% |J.",?70,"Are You Eligible for MEDICAID",?126,@EASD@("14J")
+15 WRITE ?131,$CHAR(13)
if EALNE("ULC")="-"
WRITE !
WRITE EALNE("UL")
+16 ;
+17 WRITE !?2,"C.",?6,"Are You Receiving a VA Pension: ",?58,@EASD@("14C"),?65,"|K.",?70,"Are You Enrolled in MEDICARE Hospital Insurance Part A",?126,@EASD@("14K")
+18 WRITE ?131,$CHAR(13)
if EALNE("ULC")="-"
WRITE !
WRITE EALNE("UL")
+19 ;
+20 WRITE !?2,"D.",?6,"Are You Retired From The Military: ",?58,@EASD@("14D"),?65,"|K1.",?70,"Effective Date",?110,@EASD@("14K1")
+21 WRITE ?131,$CHAR(13)
if EALNE("ULC")="-"
WRITE !
WRITE EALNE("UL")
+22 ;
+23 WRITE !?2,"D1.",?6,"Was Your Retirement The Result Of a Disability: ",?58,@EASD@("14D1"),?65,"|L.",?70,"Are You Enrolled in MEDICARE Hospital Insurance Part B",?126,@EASD@("14L")
+24 WRITE ?131,$CHAR(13)
if EALNE("ULC")="-"
WRITE !
WRITE EALNE("UL")
+25 ;
+26 WRITE !?2,"D2.",?6,"Were You Regularly Retired (20+yrs.)",?58,@EASD@("14D2"),?65,"|L1.",?70,"Effective Date",?110,@EASD@("14L1")
+27 WRITE ?131,$CHAR(13)
if EALNE("ULC")="-"
WRITE !
WRITE EALNE("UL")
+28 ;
+29 WRITE !?2,"E.",?6,"Were You Exposed To Toxins In The Gulf War",?58,@EASD@("14E"),?65,"|M.",?70,"MEDICARE Claim Number",?110,@EASD@("14M")
+30 WRITE ?131,$CHAR(13)
if EALNE("ULC")="-"
WRITE !
WRITE EALNE("UL")
+31 ;
+32 WRITE !?2,"F.",?6,"Were You Exposed To Agent Orange",?58,@EASD@("14F"),?65,"|N.",?70,"Name Exactly As It Appears On Your MEDICARE Card"
+33 WRITE ?131,$CHAR(13)
if EALNE("ULC")="-"
WRITE !
WRITE $EXTRACT(EALNE("UL"),1,65)
+34 ;
+35 WRITE !?2,"G.",?6,"Were You Exposed to Radiation",?58,@EASD@("14G"),?65,"| ",@EASD@("14N")
+36 QUIT
+37 ;
EMP ;
+1 WRITE !,EALNE("D")
+2 WRITE !,"15A. Veteran's Employment Status ",$PIECE(@EASD@("15A"),U),?58,"| 15B. Company Name, Address, Telephone"
+3 WRITE !?5,"Date of Retirement: ",$PIECE(@EASD@("15A"),U,2),?58,"| ",$PIECE(@EASD@("15B"),U)," ",$PIECE(@EASD@("15B"),U,3)
+4 WRITE !?7,"(If employed or retired, complete 15B)",?58,"| ",$PIECE(@EASD@("15B"),U,2)
+5 WRITE ?131,$CHAR(13)
if EALNE("ULC")="-"
WRITE !
WRITE EALNE("UL")
+6 ;
+7 WRITE !,"16A. Spouse's Employment Status ",$PIECE(@EASD@("16A"),U),?58,"| 16B. Company Name, Address, Telephone"
+8 WRITE !?5,"Date of Retirement: ",$PIECE(@EASD@("16A"),U,2),?58,"| ",$PIECE(@EASD@("16B"),U)," ",$PIECE(@EASD@("16B"),U,3)
+9 WRITE !?7,"(If employed or retired, complete 16B)",?58,"| ",$PIECE(@EASD@("16B"),U,2)
+10 WRITE ?131,$CHAR(13)
if EALNE("ULC")="-"
WRITE !
WRITE EALNE("UL")
+11 QUIT
+12 ;
INS ;
+1 WRITE !,"17. Does The Veteran Have Health Insurance",?65,"|18. Does The Spouse Have Health Insurance"
+2 WRITE !," (Other Than Medicare) ",@EASD@(17),?65,"| (Other Than Medicare) ",@EASD@(18)
+3 WRITE ?131,$CHAR(13)
if EALNE("ULC")="-"
WRITE !
WRITE EALNE("UL")
+4 ;
+5 WRITE !,"17A. Veteran's Health Insurance Co.",?65,"|18A. Spouse's Health Insurance Co."
+6 WRITE !?1,@EASD@("17A"),?65,"| ",@EASD@("18A")
+7 WRITE !
+8 WRITE ?131,$CHAR(13)
if EALNE("ULC")="-"
WRITE !
WRITE EALNE("UL")
+9 ;
+10 WRITE !,"17B. Name of Policy Holder ",@EASD@("17B"),?65,"|18B. Name of Policy Holder ",@EASD@("18B")
+11 WRITE ?131,$CHAR(13)
if EALNE("ULC")="-"
WRITE !
WRITE EALNE("UL")
+12 ;
+13 WRITE !,"17C. Policy Number",?32,"|17D. Group Code",?65,"|18C. Policy Number",?98,"|18D. Group Code"
+14 WRITE !,@EASD@("17C"),?32,"| ",@EASD@("17D"),?65,"| ",@EASD@("18C"),?98,"| ",@EASD@("18D")
+15 WRITE ?131,$CHAR(13)
if EALNE("ULC")="-"
WRITE !
WRITE EALNE("UL")
+16 QUIT
+17 ;
NOK ;
+1 WRITE !,"19A. Name, Address and Relationship Of Next of Kin",?80,"|19B. Home Telephone ",@EASD@("19B")
+2 WRITE !?1,$PIECE(@EASD@("19A"),U)," - ",$PIECE(@EASD@("19A"),U,3),?80,"|19C. Work Telephone ",@EASD@("19C")
+3 WRITE !?1,$PIECE(@EASD@("19A"),U,2),?80,"|"
+4 WRITE ?131,$CHAR(13)
if EALNE("ULC")="-"
WRITE !
WRITE EALNE("UL")
+5 ;
+6 WRITE !,"20A. Name, Adress and Relationship Of Emergency Contact",?80,"|20B. Home Telephone ",@EASD@("20B")
+7 WRITE !?1,$PIECE(@EASD@("20A"),U)," - ",$PIECE(@EASD@("20A"),U,3),?80,"|20C. Work Telephone ",@EASD@("20C")
+8 WRITE !?1,$PIECE(@EASD@("20A"),U,2),?80,"|"
+9 WRITE ?131,$CHAR(13)
if EALNE("ULC")="-"
WRITE !
WRITE EALNE("UL")
+10 ;
+11 WRITE !,"21. I DESIGNATE THE FOLLOWING INDIVIDUAL TO RECEIVE POSSESSION OF ALL MY PERSONAL PROPERTY LEFT ON PREMISES UNDER VA CONTROL AFTER"
+12 WRITE !," MY DEPARTURE OR AT THE TIME OF MY DEATH. (This does not constitute a will or transfer of title.) ",@EASD@(21)
+13 WRITE ?131,$CHAR(13)
if EALNE("ULC")="-"
WRITE !
WRITE EALNE("UL")
+14 ;
+15 WRITE !,"22A. Is Need For Care Due To On The Job Injury ",@EASD@("22A"),?65,"|22B. Is Need For Care Due To Accident ",@EASD@("22B")
+16 QUIT
