EASEZPF1.m

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 ---EASEZPF1   6846     printed  Mar 13, 2025@20:59:32                                                                                                                                                                                                    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