EASEZPF3 ; ALB/SCK - Print 1010EZ Enrollment Form Cont. ; 10/25/2000
;;1.0;ENROLLMENT APPLICATION SYSTEM;;Mar 15, 2001
;
EN(EALNE,EAINFO) ;
N EASIGN
;
I $$GET1^DIQ(712,EAINFO("EASAPP")_",",4)]"" D
. S EASIGN=$$GET1^DIQ(712,EAINFO("EASAPP")_",",4.1)
S EASIGN=$G(EASIGN)
;
D HDR^EASEZPF(.EALNE,.EAINFO)
D REL
D CON
D FT^EASEZPF(.EALNE,.EAINFO)
;
Q
;
REL ;
W !?55,"SECTION III",!,EALNE("DD")
W !,?50,"CONSENT TO RELEASE INFORMATION"
W !!,"I hereby authorize the Department of Veterans Affairs to disclose any such history, diagnostic and treatment information from"
W !,"my medical records (including information relating to the diagnosis, treatment of other therapy for the conditions of"
W !,"substance abuse, alcoholism or alcohol abuse, sickle cell anemia, or testing for or infection with the human immunodeficiency"
W !,"virus) to the contractor of any health plan contract under which I am apparently eligible for medical care or payment of the"
W !,"expense of care or to any other party against whom liability is asserted. I understand that I may revoke this authorization"
W !,"at any time, except to the extent that action has already been taken in reliance on it. Without my express revocation, this"
W !,"consent will automatically expire when all action arising from VA's claim for reimbursement for my medical care has been"
W !,"completed. I authorize payment of medical benefits to VA for any services for which payment is accepted."
;
W !,EALNE("D")
W !,"SOCIAL SECURITY NUMBER ",EAINFO("SSN"),?80,"| DATE OF BIRTH ",$G(^TMP("EASEZ",$J,1,7))
W ?131,$C(13) W:EALNE("ULC")="-" ! W EALNE("UL")
W !,"SIGNATURE OF PATIENT",?80,"| DATE (mm/dd/yyyy)",!
W ?131,$C(13) W:EALNE("ULC")="-" ! W EALNE("UL")
W !!,EALNE("D"),!?50,"III - CONSENT AND SIGNATURE"
W !?30,"ALL APPLICANTS MUST SIGN AND DATE THE APPLICATION FOR HEALTH BENEFITS"
W !,EALNE("D")
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"
W !,"not required to respond to, a collection of information unless it displays a valid OMB number. We anticipate that the"
W !,"time expended by all individuals who must complete this form will average 20 minutes. This includes the time it will take"
W !,"to read instructions, gather the necessary facts and fill out the form."
W !!,"Privacy Act Information: The VA is asking you to provide the information on this form under Title 38, United States Code, "
W !,"sections 1710, 1712, and 1722 in order for VA to determine your eligibility for medical benefits. The information you supply"
W !,"may be verified through a computer-matching program. VA may disclose the information that you put on the form as permitted by"
W !,"law. VA may make a ""routine use"" disclosure for: civil or criminal law enforcement, congressional communications, "
W !,"epidemiological or research studies, the collection of money owed to the United States, litigation in which the United States"
W !,"is a party or has interest, the administration of VA programs and delivery of VA benefits, verification of identity and status,"
W !,"and personnel administration. You do not have to provide the information to VA, but if you don't, we will be unable to "
W !,"process your request and serve your medical needs. Failure to furnish the information will not have any affect on any other "
W !,"benefits to which you may be entitled. If you give VA your Social Security Number, VA will use it to administer your VA "
W !,"benefits, to identify veterans and persons claiming or receiving VA benefits and their records, and for other purposes "
W !,"authorized or required by law."
Q
;
CON ;
W !!,"CO-PAYMENT NOTICE: If you are a 0% service-connected noncompensable or a nonservice-connected veteran (and are not an"
W !,"Ex-POW, WWI veteran or VA pensioner) AND your household income (or combined income and net worth) exceeds the established"
W !,"threshold, you may be eligible for enrollment only if you agree to pay VA co-payments for treatment of your NSC conditions."
W !,"By signing this application you are agreeing to pay the applicable VA co-payment if required by law.",!
W ?131,$C(13) W:EALNE("ULC")="-" ! W EALNE("UL")
W !,?5,"I CERTIFY THE FOREGOING STATEMENT(S) ARE TRUE AND CORRECT TO THE BEST OF MY KNOWLEDGE AND ABILITY.",?110,"|Date (mm/dd/yyyy)"
W !?110,"|",!,"SIGN HERE "
I $G(EASIGN)]"" W "SIGNATURE OF APPLICANT OR APPLICANT'S REPRESENTATIVE HAS BEEN VERIFIED",?110,"| ",EASIGN
W ?131,$C(13) W:EALNE("ULC")="-" ! W EALNE("UL")
;
W !,EALNE("DD"),!?24,"THE LAW PROVIDES SEVERE PENALTIES FOR WILLFUL SUBMISSION OF FALSE INFORMATION."
Q
--- Routine Detail --- with STRUCTURED ROUTINE LISTING ---[H[J[2J[HEASEZPF3 4882 printed Sep 23, 2025@19:30:58 Page 2
EASEZPF3 ; ALB/SCK - Print 1010EZ Enrollment Form Cont. ; 10/25/2000
+1 ;;1.0;ENROLLMENT APPLICATION SYSTEM;;Mar 15, 2001
+2 ;
EN(EALNE,EAINFO) ;
+1 NEW EASIGN
+2 ;
+3 IF $$GET1^DIQ(712,EAINFO("EASAPP")_",",4)]""
Begin DoDot:1
+4 SET EASIGN=$$GET1^DIQ(712,EAINFO("EASAPP")_",",4.1)
End DoDot:1
+5 SET EASIGN=$GET(EASIGN)
+6 ;
+7 DO HDR^EASEZPF(.EALNE,.EAINFO)
+8 DO REL
+9 DO CON
+10 DO FT^EASEZPF(.EALNE,.EAINFO)
+11 ;
+12 QUIT
+13 ;
REL ;
+1 WRITE !?55,"SECTION III",!,EALNE("DD")
+2 WRITE !,?50,"CONSENT TO RELEASE INFORMATION"
+3 WRITE !!,"I hereby authorize the Department of Veterans Affairs to disclose any such history, diagnostic and treatment information from"
+4 WRITE !,"my medical records (including information relating to the diagnosis, treatment of other therapy for the conditions of"
+5 WRITE !,"substance abuse, alcoholism or alcohol abuse, sickle cell anemia, or testing for or infection with the human immunodeficiency"
+6 WRITE !,"virus) to the contractor of any health plan contract under which I am apparently eligible for medical care or payment of the"
+7 WRITE !,"expense of care or to any other party against whom liability is asserted. I understand that I may revoke this authorization"
+8 WRITE !,"at any time, except to the extent that action has already been taken in reliance on it. Without my express revocation, this"
+9 WRITE !,"consent will automatically expire when all action arising from VA's claim for reimbursement for my medical care has been"
+10 WRITE !,"completed. I authorize payment of medical benefits to VA for any services for which payment is accepted."
+11 ;
+12 WRITE !,EALNE("D")
+13 WRITE !,"SOCIAL SECURITY NUMBER ",EAINFO("SSN"),?80,"| DATE OF BIRTH ",$GET(^TMP("EASEZ",$JOB,1,7))
+14 WRITE ?131,$CHAR(13)
if EALNE("ULC")="-"
WRITE !
WRITE EALNE("UL")
+15 WRITE !,"SIGNATURE OF PATIENT",?80,"| DATE (mm/dd/yyyy)",!
+16 WRITE ?131,$CHAR(13)
if EALNE("ULC")="-"
WRITE !
WRITE EALNE("UL")
+17 WRITE !!,EALNE("D"),!?50,"III - CONSENT AND SIGNATURE"
+18 WRITE !?30,"ALL APPLICANTS MUST SIGN AND DATE THE APPLICATION FOR HEALTH BENEFITS"
+19 WRITE !,EALNE("D")
+20 WRITE !,"The Paperwork Reduction Act of 1995 requires us to notify you that this information collection is in accordance with the"
+21 WRITE !,"clearance requirements of section 3507 of the Paperwork Reduction Act of 1995. We may not conduct or sponsor, and you are"
+22 WRITE !,"not required to respond to, a collection of information unless it displays a valid OMB number. We anticipate that the"
+23 WRITE !,"time expended by all individuals who must complete this form will average 20 minutes. This includes the time it will take"
+24 WRITE !,"to read instructions, gather the necessary facts and fill out the form."
+25 WRITE !!,"Privacy Act Information: The VA is asking you to provide the information on this form under Title 38, United States Code, "
+26 WRITE !,"sections 1710, 1712, and 1722 in order for VA to determine your eligibility for medical benefits. The information you supply"
+27 WRITE !,"may be verified through a computer-matching program. VA may disclose the information that you put on the form as permitted by"
+28 WRITE !,"law. VA may make a ""routine use"" disclosure for: civil or criminal law enforcement, congressional communications, "
+29 WRITE !,"epidemiological or research studies, the collection of money owed to the United States, litigation in which the United States"
+30 WRITE !,"is a party or has interest, the administration of VA programs and delivery of VA benefits, verification of identity and status,"
+31 WRITE !,"and personnel administration. You do not have to provide the information to VA, but if you don't, we will be unable to "
+32 WRITE !,"process your request and serve your medical needs. Failure to furnish the information will not have any affect on any other "
+33 WRITE !,"benefits to which you may be entitled. If you give VA your Social Security Number, VA will use it to administer your VA "
+34 WRITE !,"benefits, to identify veterans and persons claiming or receiving VA benefits and their records, and for other purposes "
+35 WRITE !,"authorized or required by law."
+36 QUIT
+37 ;
CON ;
+1 WRITE !!,"CO-PAYMENT NOTICE: If you are a 0% service-connected noncompensable or a nonservice-connected veteran (and are not an"
+2 WRITE !,"Ex-POW, WWI veteran or VA pensioner) AND your household income (or combined income and net worth) exceeds the established"
+3 WRITE !,"threshold, you may be eligible for enrollment only if you agree to pay VA co-payments for treatment of your NSC conditions."
+4 WRITE !,"By signing this application you are agreeing to pay the applicable VA co-payment if required by law.",!
+5 WRITE ?131,$CHAR(13)
if EALNE("ULC")="-"
WRITE !
WRITE EALNE("UL")
+6 WRITE !,?5,"I CERTIFY THE FOREGOING STATEMENT(S) ARE TRUE AND CORRECT TO THE BEST OF MY KNOWLEDGE AND ABILITY.",?110,"|Date (mm/dd/yyyy)"
+7 WRITE !?110,"|",!,"SIGN HERE "
+8 IF $GET(EASIGN)]""
WRITE "SIGNATURE OF APPLICANT OR APPLICANT'S REPRESENTATIVE HAS BEEN VERIFIED",?110,"| ",EASIGN
+9 WRITE ?131,$CHAR(13)
if EALNE("ULC")="-"
WRITE !
WRITE EALNE("UL")
+10 ;
+11 WRITE !,EALNE("DD"),!?24,"THE LAW PROVIDES SEVERE PENALTIES FOR WILLFUL SUBMISSION OF FALSE INFORMATION."
+12 QUIT
