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Routine: EASEZPF3

Package: Enrollment Application System

Routine: EASEZPF3


Information

EASEZPF3 ; ALB/SCK - Print 1010EZ Enrollment Form Cont. ; 10/25/2000

Source Information

Source file <EASEZPF3.m>

Entry Points

Name Comments DBIA/ICR reference
EN(EALNE,EAINFO) ;
REL ;
CON ;

Interaction Calls

Name Line Occurrences
Function Call: WRITE
  • Prompt: !?55,"SECTION III",!,EALNE("DD")
  • Line Location: REL+1
Function Call: WRITE
  • Prompt: !,?50,"CONSENT TO RELEASE INFORMATION"
  • Line Location: REL+2
Function Call: WRITE
  • Prompt: !!,"I hereby authorize the Department of Veterans Affairs to disclose any such history, diagnostic and treatment information from"
  • Line Location: REL+3
Function Call: WRITE
  • Prompt: !,"my medical records (including information relating to the diagnosis, treatment of other therapy for the conditions of"
  • Line Location: REL+4
Function Call: WRITE
  • Prompt: !,"substance abuse, alcoholism or alcohol abuse, sickle cell anemia, or testing for or infection with the human immunodeficiency"
  • Line Location: REL+5
Function Call: WRITE
  • Prompt: !,"virus) to the contractor of any health plan contract under which I am apparently eligible for medical care or payment of the"
  • Line Location: REL+6
Function Call: WRITE
  • Prompt: !,"expense of care or to any other party against whom liability is asserted. I understand that I may revoke this authorization"
  • Line Location: REL+7
Function Call: WRITE
  • Prompt: !,"at any time, except to the extent that action has already been taken in reliance on it. Without my express revocation, this"
  • Line Location: REL+8
Function Call: WRITE
  • Prompt: !,"consent will automatically expire when all action arising from VA's claim for reimbursement for my medical care has been"
  • Line Location: REL+9
Function Call: WRITE
  • Prompt: !,"completed. I authorize payment of medical benefits to VA for any services for which payment is accepted."
  • Line Location: REL+10
Function Call: WRITE
  • Prompt: !,EALNE("D")
  • Line Location: REL+12
Function Call: WRITE
  • Prompt: !,"SOCIAL SECURITY NUMBER ",EAINFO("SSN"),?80,"| DATE OF BIRTH ",$G(^TMP("EASEZ",$J,1,7))
  • Line Location: REL+13
Function Call: WRITE
  • Prompt: ?131,$C(13)
  • Line Location: REL+14
Function Call: WRITE
  • Prompt: !
  • Condition for execution: EALNE("ULC")="-"
  • Line Location: REL+14
Function Call: WRITE
  • Prompt: EALNE("UL")
  • Line Location: REL+14
Function Call: WRITE
  • Prompt: !,"SIGNATURE OF PATIENT",?80,"| DATE (mm/dd/yyyy)",!
  • Line Location: REL+15
Function Call: WRITE
  • Prompt: ?131,$C(13)
  • Line Location: REL+16
Function Call: WRITE
  • Prompt: !
  • Condition for execution: EALNE("ULC")="-"
  • Line Location: REL+16
Function Call: WRITE
  • Prompt: EALNE("UL")
  • Line Location: REL+16
Function Call: WRITE
  • Prompt: !!,EALNE("D"),!?50,"III - CONSENT AND SIGNATURE"
  • Line Location: REL+17
Function Call: WRITE
  • Prompt: !?30,"ALL APPLICANTS MUST SIGN AND DATE THE APPLICATION FOR HEALTH BENEFITS"
  • Line Location: REL+18
Function Call: WRITE
  • Prompt: !,EALNE("D")
  • Line Location: REL+19
Function Call: WRITE
  • Prompt: !,"The Paperwork Reduction Act of 1995 requires us to notify you that this information collection is in accordance with the"
  • Line Location: REL+20
Function Call: WRITE
  • Prompt: !,"clearance requirements of section 3507 of the Paperwork Reduction Act of 1995. We may not conduct or sponsor, and you are"
  • Line Location: REL+21
Function Call: WRITE
  • Prompt: !,"not required to respond to, a collection of information unless it displays a valid OMB number. We anticipate that the"
  • Line Location: REL+22
Function Call: WRITE
  • Prompt: !,"time expended by all individuals who must complete this form will average 20 minutes. This includes the time it will take"
  • Line Location: REL+23
Function Call: WRITE
  • Prompt: !,"to read instructions, gather the necessary facts and fill out the form."
  • Line Location: REL+24
Function Call: WRITE
  • Prompt: !!,"Privacy Act Information: The VA is asking you to provide the information on this form under Title 38, United States Code, "
  • Line Location: REL+25
Function Call: WRITE
  • Prompt: !,"sections 1710, 1712, and 1722 in order for VA to determine your eligibility for medical benefits. The information you supply"
  • Line Location: REL+26
Function Call: WRITE
  • Prompt: !,"may be verified through a computer-matching program. VA may disclose the information that you put on the form as permitted by"
  • Line Location: REL+27
Function Call: WRITE
  • Prompt: !,"law. VA may make a ""routine use"" disclosure for: civil or criminal law enforcement, congressional communications, "
  • Line Location: REL+28
Function Call: WRITE
  • Prompt: !,"epidemiological or research studies, the collection of money owed to the United States, litigation in which the United States"
  • Line Location: REL+29
Function Call: WRITE
  • Prompt: !,"is a party or has interest, the administration of VA programs and delivery of VA benefits, verification of identity and status,"
  • Line Location: REL+30
Function Call: WRITE
  • Prompt: !,"and personnel administration. You do not have to provide the information to VA, but if you don't, we will be unable to "
  • Line Location: REL+31
Function Call: WRITE
  • Prompt: !,"process your request and serve your medical needs. Failure to furnish the information will not have any affect on any other "
  • Line Location: REL+32
Function Call: WRITE
  • Prompt: !,"benefits to which you may be entitled. If you give VA your Social Security Number, VA will use it to administer your VA "
  • Line Location: REL+33
Function Call: WRITE
  • Prompt: !,"benefits, to identify veterans and persons claiming or receiving VA benefits and their records, and for other purposes "
  • Line Location: REL+34
Function Call: WRITE
  • Prompt: !,"authorized or required by law."
  • Line Location: REL+35
Function Call: WRITE
  • Prompt: !!,"CO-PAYMENT NOTICE: If you are a 0% service-connected noncompensable or a nonservice-connected veteran (and are not an"
  • Line Location: CON+1
Function Call: WRITE
  • Prompt: !,"Ex-POW, WWI veteran or VA pensioner) AND your household income (or combined income and net worth) exceeds the established"
  • Line Location: CON+2
Function Call: WRITE
  • Prompt: !,"threshold, you may be eligible for enrollment only if you agree to pay VA co-payments for treatment of your NSC conditions."
  • Line Location: CON+3
Function Call: WRITE
  • Prompt: !,"By signing this application you are agreeing to pay the applicable VA co-payment if required by law.",!
  • Line Location: CON+4
Function Call: WRITE
  • Prompt: ?131,$C(13)
  • Line Location: CON+5
Function Call: WRITE
  • Prompt: !
  • Condition for execution: EALNE("ULC")="-"
  • Line Location: CON+5
Function Call: WRITE
  • Prompt: EALNE("UL")
  • Line Location: CON+5
Function Call: WRITE
  • Prompt: !,?5,"I CERTIFY THE FOREGOING STATEMENT(S) ARE TRUE AND CORRECT TO THE BEST OF MY KNOWLEDGE AND ABILITY.",?110,"|Date (mm/dd/yyyy)"
  • Line Location: CON+6
Function Call: WRITE
  • Prompt: !?110,"|",!,"SIGN HERE "
  • Line Location: CON+7
Function Call: WRITE
  • Prompt: "SIGNATURE OF APPLICANT OR APPLICANT'S REPRESENTATIVE HAS BEEN VERIFIED",?110,"| ",EASIGN
  • Line Location: CON+8
Function Call: WRITE
  • Prompt: ?131,$C(13)
  • Line Location: CON+9
Function Call: WRITE
  • Prompt: !
  • Condition for execution: EALNE("ULC")="-"
  • Line Location: CON+9
Function Call: WRITE
  • Prompt: EALNE("UL")
  • Line Location: CON+9
Function Call: WRITE
  • Prompt: !,EALNE("DD"),!?24,"THE LAW PROVIDES SEVERE PENALTIES FOR WILLFUL SUBMISSION OF FALSE INFORMATION."
  • Line Location: CON+11

FileMan Files Accessed Via FileMan Db Call

FileNo Call Tags
^EAS(712 - [#712] GET1^DIQ
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