- EASEZRP1 ;ALB/AMA,TDM - Print 1010EZR ; 3/14/13 10:52am
- ;;1.0;ENROLLMENT APPLICATION SYSTEM;**57,70,107**;Mar 15, 2001;Build 32
- ;
- EN(EALNE,EAINFO) ;Entry point for VA 10-10EZR, page 1
- ; Called from EN^EASEZRPF
- N EASD,X
- ;
- S EASD=$NA(^TMP("EASEZR",$J,1))
- D HDRMAIN^EASEZRPF(.EALNE)
- D DEM
- D II
- D EI
- D FD^EASEZRP2
- ;
- D FT^EASEZRPF(.EALNE,.EAINFO)
- S EAINFO("VET")=@EASD@(2),EAINFO("SSN")=@EASD@(5)
- Q
- ;
- DEM ; Print VA 10-10EZR Section I, Demographic information
- ;
- W !?50,"SECTION I - GENERAL INFORMATION"
- W ?131,$C(13) W:EALNE("ULC")="-" ! W EALNE("UL")
- W !?18,"Federal law provides criminal penalties, including a fine and/or imprisonment for up to 5 years,"
- W !?20,"for concealing a material fact or making a materially false statement. (See 18 U.S.C. 1001)"
- W ?131,$C(13) W:EALNE("ULC")="-" ! W EALNE("UL")
- ;
- W !,"1. VETERAN'S NAME (Last, First, Middle Name)",?95,"|2. OTHER NAMES USED"
- W !?3,@EASD@(2),?95,"| ",@EASD@(3)
- W ?131,$C(13) W:EALNE("ULC")="-" ! W EALNE("UL")
- ;
- W !,"3. GENDER",?20,"|4. SOCIAL SECURITY NUMBER",?95,"|5. DATE OF BIRTH (mm/dd/yyyy)"
- W !?3,@EASD@(4),?20,"| ",@EASD@(5),?95,"| ",@EASD@(7)
- W ?131,$C(13) W:EALNE("ULC")="-" ! W EALNE("UL")
- ;
- ;EAS*1.0*70 - CHECK FOR FOREIGN ADDRESS
- I $G(@EASD@("9H"))="UNITED STATES" D I 1 ;Use domestic address field labels
- . W !,"6. PERMANENT ADDRESS (Street)",?46,"|6A. CITY",?85,"|6B. STATE",?105,"|6C. ZIP"
- . W !?3,@EASD@("9A"),?46,"| ",@EASD@("9B"),?85,"| ",@EASD@("9C"),?105,"| ",@EASD@("9D")
- . W ?131,$C(13) W:EALNE("ULC")="-" ! W EALNE("UL")
- . ;
- . W !,"6D. COUNTY",?66,"|6E. HOME TELEPHONE NUMBER (Include area code)"
- . W !?4,@EASD@("9E"),?66,"| ",@EASD@(10)
- ;
- E D ;Use foreign address field labels
- . W !,"6. PERMANENT ADDRESS (Street)",?46,"|6A. CITY",?85,"|6B. PROVINCE",?105,"|6C. POSTAL CODE"
- . W !?3,@EASD@("9A"),?46,"| ",@EASD@("9B"),?85,"| ",@EASD@("9F"),?105,"| ",@EASD@("9G")
- . W ?131,$C(13) W:EALNE("ULC")="-" ! W EALNE("UL")
- . ;
- . W !,"6D. COUNTRY",?66,"|6E. HOME TELEPHONE NUMBER (Include area code)"
- . W !?4,@EASD@("9H"),?34,"| ",@EASD@(10)
- W ?131,$C(13) W:EALNE("ULC")="-" ! W EALNE("UL")
- W !,"6F. E-MAIL ADDRESS",?66,"|6G. CELLULAR TELEPHONE NUMBER (Include area code)"
- W !,?4,@EASD@("11A"),?66,"| ",@EASD@("11G")
- ;
- W ?131,$C(13) W:EALNE("ULC")="-" ! W EALNE("UL")
- ;
- W !,"7. CURRENT MARITAL STATUS"
- W !,?3,@EASD@(12)
- W ?131,$C(13) W:EALNE("ULC")="-" ! W EALNE("UL")
- ;
- W !,"8. NAME, ADDRESS AND RELATIONSHIP OF NEXT OF KIN",?83,"|8A. NEXT OF KIN'S HOME TELEPHONE NUMBER"
- W !?3,$P(@EASD@("19A"),U)," - ",$P(@EASD@("19A"),U,4),?83,"| (Include area code) ",@EASD@("19B")
- W ?131,$C(13) W:EALNE("ULC")="-" ! F X=1:1:84 W " "
- W $E(EALNE("UL"),1,48)
- W !?3,$P(@EASD@("19A"),U,2),?83,"|8B. NEXT OF KIN'S WORK TELEPHONE NUMBER"
- W !?3,$P(@EASD@("19A"),U,3),?83,"| (Include area code) ",@EASD@("19C")
- W ?131,$C(13) W:EALNE("ULC")="-" ! W EALNE("UL")
- ;
- W !,"9. NAME, ADDRESS AND RELATIONSHIP OF EMERGENCY CONTACT",?83,"|9A. EMERGENCY CONTACT'S HOME TELEPHONE NUMBER"
- W !?3,$P(@EASD@("20A"),U)," - ",$P(@EASD@("20A"),U,4),?83,"| (Include area code) ",@EASD@("20B")
- W ?131,$C(13) W:EALNE("ULC")="-" ! F X=1:1:84 W " "
- W $E(EALNE("UL"),1,48)
- W !?3,$P(@EASD@("20A"),U,2),?83,"|9B. EMERGENCY CONTACT'S WORK TELEPHONE NUMBER"
- W !?3,$P(@EASD@("20A"),U,3),?83,"| (Include area code) ",@EASD@("20C")
- W ?131,$C(13) W:EALNE("ULC")="-" ! W EALNE("UL")
- ;
- ;W !,"10. INDIVIDUAL TO RECEIVE POSSESSION OF YOUR PERSONAL PROPERTY LEFT ON PREMISES UNDER VA CONTROL AFTER YOUR DEPARTURE OR AT THE"
- ;W !?4,"TIME OF DEATH. Note: This does not constitute a will or transfer of title. ",@EASD@(21)
- ;W ?131,$C(13) W:EALNE("ULC")="-" ! W EALNE("UL")
- Q
- ;
- II ; Print VA 10-10EZR SECTION II - INSURANCE INFORMATION
- ;
- W !?23,"SECTION II - INSURANCE INFORMATION (Use a separate sheet for additional information)"
- W ?131,$C(13) W:EALNE("ULC")="-" ! W EALNE("UL")
- ;
- W !,"1. ARE YOU COVERED BY HEALTH INSURANCE,",?49,"|2. HEALTH INSURANCE COMPANY NAME, ADDRESS AND TELEPHONE NUMBER"
- W !?3,"INCLUDING COVERAGE THROUGH A SPOUSE",?49,"| ",@EASD@("17A")
- W !?3,"OR ANOTHER PERSON? ",@EASD@(17),?49,"| "
- W ?131,$C(13) W:EALNE("ULC")="-" ! W $E(EALNE("UL"),1,49)
- ;
- W !,"3. NAME OF POLICY HOLDER",?49,"| ",$P(@EASD@("17E"),U,2)
- W !?3,@EASD@("17B"),?49,"| ",@EASD@("17I")
- W ?131,$C(13) W:EALNE("ULC")="-" ! W EALNE("UL")
- ;
- W !,"4. POLICY NUMBER",?41,"|5. GROUP CODE",?70,"|6. ARE YOU ELIGIBLE FOR MEDICAID?",?111,"|6A. EFFECTIVE DATE"
- W !?3,@EASD@("17C"),?41,"| ",@EASD@("17D"),?70,"| ",@EASD@("14J"),?111,"| "
- W ?131,$C(13) W:EALNE("ULC")="-" ! W EALNE("UL")
- ;
- W !,"7. ARE YOU ENROLLED IN MEDICARE HOSPITAL INSURANCE PART A?",?70,"|7A. EFFECTIVE DATE (mm/dd/yyyy)"
- W !?3,@EASD@("14K"),?70,"| ",@EASD@("14K1")
- W ?131,$C(13) W:EALNE("ULC")="-" ! W EALNE("UL")
- ;
- W !,"8. ARE YOU ENROLLED IN MEDICARE HOSPITAL INSURANCE PART B?",?70,"|8A. EFFECTIVE DATE (mm/dd/yyyy)"
- W !?3,@EASD@("14L"),?70,"| ",@EASD@("14L1")
- W ?131,$C(13) W:EALNE("ULC")="-" ! W EALNE("UL")
- ;
- W !,"9. NAME EXACTLY AS IT APPEARS ON YOUR MEDICARE CARD",?70,"|10. MEDICARE CLAIM NUMBER"
- W !?3,@EASD@("14N"),?70,"| ",@EASD@("14M")
- W ?131,$C(13) W:EALNE("ULC")="-" ! W EALNE("UL")
- Q
- ;
- EI ; Print VA 10-10EZR SECTION III - EMPLOYMENT INFORMATION
- ;
- W !?48,"SECTION III - EMPLOYMENT INFORMATION"
- W ?131,$C(13) W:EALNE("ULC")="-" ! W EALNE("UL")
- ;
- W !,"1. VETERAN'S EMPLOYMENT STATUS",?47,"|1A. COMPANY NAME, ADDRESS AND TELEPHONE NUMBER"
- W !?3,$P(@EASD@("15A"),U),?47,"| ",$P(@EASD@("15B"),U)
- W !,"Date of retirement (mm/dd/yyyy) ",$P(@EASD@("15A"),U,2),?47,"| ",$P(@EASD@("15B"),U,2)
- W !,"If employed or retired, complete item 1A",?47,"| ",$P(@EASD@("15B"),U,3)
- W !?47," ",$P(@EASD@("15B"),U,4)
- W ?131,$C(13) W:EALNE("ULC")="-" ! W EALNE("UL")
- ;
- W !,"2. SPOUSE'S EMPLOYMENT STATUS",?47,"|2A. COMPANY NAME, ADDRESS AND TELEPHONE NUMBER"
- W !?3,$P(@EASD@("16A"),U),?47,"| ",$P(@EASD@("16B"),U)
- W !,"Date of retirement (mm/dd/yyyy) ",$P(@EASD@("16A"),U,2),?47,"| ",$P(@EASD@("16B"),U,2)
- W !,"If employed or retired, complete item 2A",?47,"| ",$P(@EASD@("16B"),U,3)
- W !?47,"| ",$P(@EASD@("16B"),U,4)
- W ?131,$C(13) W:EALNE("ULC")="-" ! W EALNE("UL")
- Q
- --- Routine Detail --- with STRUCTURED ROUTINE LISTING ---[H[J[2J[HEASEZRP1 6396 printed Feb 18, 2025@23:21:26 Page 2
- EASEZRP1 ;ALB/AMA,TDM - Print 1010EZR ; 3/14/13 10:52am
- +1 ;;1.0;ENROLLMENT APPLICATION SYSTEM;**57,70,107**;Mar 15, 2001;Build 32
- +2 ;
- EN(EALNE,EAINFO) ;Entry point for VA 10-10EZR, page 1
- +1 ; Called from EN^EASEZRPF
- +2 NEW EASD,X
- +3 ;
- +4 SET EASD=$NAME(^TMP("EASEZR",$JOB,1))
- +5 DO HDRMAIN^EASEZRPF(.EALNE)
- +6 DO DEM
- +7 DO II
- +8 DO EI
- +9 DO FD^EASEZRP2
- +10 ;
- +11 DO FT^EASEZRPF(.EALNE,.EAINFO)
- +12 SET EAINFO("VET")=@EASD@(2)
- SET EAINFO("SSN")=@EASD@(5)
- +13 QUIT
- +14 ;
- DEM ; Print VA 10-10EZR Section I, Demographic information
- +1 ;
- +2 WRITE !?50,"SECTION I - GENERAL INFORMATION"
- +3 WRITE ?131,$CHAR(13)
- if EALNE("ULC")="-"
- WRITE !
- WRITE EALNE("UL")
- +4 WRITE !?18,"Federal law provides criminal penalties, including a fine and/or imprisonment for up to 5 years,"
- +5 WRITE !?20,"for concealing a material fact or making a materially false statement. (See 18 U.S.C. 1001)"
- +6 WRITE ?131,$CHAR(13)
- if EALNE("ULC")="-"
- WRITE !
- WRITE EALNE("UL")
- +7 ;
- +8 WRITE !,"1. VETERAN'S NAME (Last, First, Middle Name)",?95,"|2. OTHER NAMES USED"
- +9 WRITE !?3,@EASD@(2),?95,"| ",@EASD@(3)
- +10 WRITE ?131,$CHAR(13)
- if EALNE("ULC")="-"
- WRITE !
- WRITE EALNE("UL")
- +11 ;
- +12 WRITE !,"3. GENDER",?20,"|4. SOCIAL SECURITY NUMBER",?95,"|5. DATE OF BIRTH (mm/dd/yyyy)"
- +13 WRITE !?3,@EASD@(4),?20,"| ",@EASD@(5),?95,"| ",@EASD@(7)
- +14 WRITE ?131,$CHAR(13)
- if EALNE("ULC")="-"
- WRITE !
- WRITE EALNE("UL")
- +15 ;
- +16 ;EAS*1.0*70 - CHECK FOR FOREIGN ADDRESS
- +17 ;Use domestic address field labels
- IF $GET(@EASD@("9H"))="UNITED STATES"
- Begin DoDot:1
- +18 WRITE !,"6. PERMANENT ADDRESS (Street)",?46,"|6A. CITY",?85,"|6B. STATE",?105,"|6C. ZIP"
- +19 WRITE !?3,@EASD@("9A"),?46,"| ",@EASD@("9B"),?85,"| ",@EASD@("9C"),?105,"| ",@EASD@("9D")
- +20 WRITE ?131,$CHAR(13)
- if EALNE("ULC")="-"
- WRITE !
- WRITE EALNE("UL")
- +21 ;
- +22 WRITE !,"6D. COUNTY",?66,"|6E. HOME TELEPHONE NUMBER (Include area code)"
- +23 WRITE !?4,@EASD@("9E"),?66,"| ",@EASD@(10)
- End DoDot:1
- IF 1
- +24 ;
- +25 ;Use foreign address field labels
- IF '$TEST
- Begin DoDot:1
- +26 WRITE !,"6. PERMANENT ADDRESS (Street)",?46,"|6A. CITY",?85,"|6B. PROVINCE",?105,"|6C. POSTAL CODE"
- +27 WRITE !?3,@EASD@("9A"),?46,"| ",@EASD@("9B"),?85,"| ",@EASD@("9F"),?105,"| ",@EASD@("9G")
- +28 WRITE ?131,$CHAR(13)
- if EALNE("ULC")="-"
- WRITE !
- WRITE EALNE("UL")
- +29 ;
- +30 WRITE !,"6D. COUNTRY",?66,"|6E. HOME TELEPHONE NUMBER (Include area code)"
- +31 WRITE !?4,@EASD@("9H"),?34,"| ",@EASD@(10)
- End DoDot:1
- +32 WRITE ?131,$CHAR(13)
- if EALNE("ULC")="-"
- WRITE !
- WRITE EALNE("UL")
- +33 WRITE !,"6F. E-MAIL ADDRESS",?66,"|6G. CELLULAR TELEPHONE NUMBER (Include area code)"
- +34 WRITE !,?4,@EASD@("11A"),?66,"| ",@EASD@("11G")
- +35 ;
- +36 WRITE ?131,$CHAR(13)
- if EALNE("ULC")="-"
- WRITE !
- WRITE EALNE("UL")
- +37 ;
- +38 WRITE !,"7. CURRENT MARITAL STATUS"
- +39 WRITE !,?3,@EASD@(12)
- +40 WRITE ?131,$CHAR(13)
- if EALNE("ULC")="-"
- WRITE !
- WRITE EALNE("UL")
- +41 ;
- +42 WRITE !,"8. NAME, ADDRESS AND RELATIONSHIP OF NEXT OF KIN",?83,"|8A. NEXT OF KIN'S HOME TELEPHONE NUMBER"
- +43 WRITE !?3,$PIECE(@EASD@("19A"),U)," - ",$PIECE(@EASD@("19A"),U,4),?83,"| (Include area code) ",@EASD@("19B")
- +44 WRITE ?131,$CHAR(13)
- if EALNE("ULC")="-"
- WRITE !
- FOR X=1:1:84
- WRITE " "
- +45 WRITE $EXTRACT(EALNE("UL"),1,48)
- +46 WRITE !?3,$PIECE(@EASD@("19A"),U,2),?83,"|8B. NEXT OF KIN'S WORK TELEPHONE NUMBER"
- +47 WRITE !?3,$PIECE(@EASD@("19A"),U,3),?83,"| (Include area code) ",@EASD@("19C")
- +48 WRITE ?131,$CHAR(13)
- if EALNE("ULC")="-"
- WRITE !
- WRITE EALNE("UL")
- +49 ;
- +50 WRITE !,"9. NAME, ADDRESS AND RELATIONSHIP OF EMERGENCY CONTACT",?83,"|9A. EMERGENCY CONTACT'S HOME TELEPHONE NUMBER"
- +51 WRITE !?3,$PIECE(@EASD@("20A"),U)," - ",$PIECE(@EASD@("20A"),U,4),?83,"| (Include area code) ",@EASD@("20B")
- +52 WRITE ?131,$CHAR(13)
- if EALNE("ULC")="-"
- WRITE !
- FOR X=1:1:84
- WRITE " "
- +53 WRITE $EXTRACT(EALNE("UL"),1,48)
- +54 WRITE !?3,$PIECE(@EASD@("20A"),U,2),?83,"|9B. EMERGENCY CONTACT'S WORK TELEPHONE NUMBER"
- +55 WRITE !?3,$PIECE(@EASD@("20A"),U,3),?83,"| (Include area code) ",@EASD@("20C")
- +56 WRITE ?131,$CHAR(13)
- if EALNE("ULC")="-"
- WRITE !
- WRITE EALNE("UL")
- +57 ;
- +58 ;W !,"10. INDIVIDUAL TO RECEIVE POSSESSION OF YOUR PERSONAL PROPERTY LEFT ON PREMISES UNDER VA CONTROL AFTER YOUR DEPARTURE OR AT THE"
- +59 ;W !?4,"TIME OF DEATH. Note: This does not constitute a will or transfer of title. ",@EASD@(21)
- +60 ;W ?131,$C(13) W:EALNE("ULC")="-" ! W EALNE("UL")
- +61 QUIT
- +62 ;
- II ; Print VA 10-10EZR SECTION II - INSURANCE INFORMATION
- +1 ;
- +2 WRITE !?23,"SECTION II - INSURANCE INFORMATION (Use a separate sheet for additional information)"
- +3 WRITE ?131,$CHAR(13)
- if EALNE("ULC")="-"
- WRITE !
- WRITE EALNE("UL")
- +4 ;
- +5 WRITE !,"1. ARE YOU COVERED BY HEALTH INSURANCE,",?49,"|2. HEALTH INSURANCE COMPANY NAME, ADDRESS AND TELEPHONE NUMBER"
- +6 WRITE !?3,"INCLUDING COVERAGE THROUGH A SPOUSE",?49,"| ",@EASD@("17A")
- +7 WRITE !?3,"OR ANOTHER PERSON? ",@EASD@(17),?49,"| "
- +8 WRITE ?131,$CHAR(13)
- if EALNE("ULC")="-"
- WRITE !
- WRITE $EXTRACT(EALNE("UL"),1,49)
- +9 ;
- +10 WRITE !,"3. NAME OF POLICY HOLDER",?49,"| ",$PIECE(@EASD@("17E"),U,2)
- +11 WRITE !?3,@EASD@("17B"),?49,"| ",@EASD@("17I")
- +12 WRITE ?131,$CHAR(13)
- if EALNE("ULC")="-"
- WRITE !
- WRITE EALNE("UL")
- +13 ;
- +14 WRITE !,"4. POLICY NUMBER",?41,"|5. GROUP CODE",?70,"|6. ARE YOU ELIGIBLE FOR MEDICAID?",?111,"|6A. EFFECTIVE DATE"
- +15 WRITE !?3,@EASD@("17C"),?41,"| ",@EASD@("17D"),?70,"| ",@EASD@("14J"),?111,"| "
- +16 WRITE ?131,$CHAR(13)
- if EALNE("ULC")="-"
- WRITE !
- WRITE EALNE("UL")
- +17 ;
- +18 WRITE !,"7. ARE YOU ENROLLED IN MEDICARE HOSPITAL INSURANCE PART A?",?70,"|7A. EFFECTIVE DATE (mm/dd/yyyy)"
- +19 WRITE !?3,@EASD@("14K"),?70,"| ",@EASD@("14K1")
- +20 WRITE ?131,$CHAR(13)
- if EALNE("ULC")="-"
- WRITE !
- WRITE EALNE("UL")
- +21 ;
- +22 WRITE !,"8. ARE YOU ENROLLED IN MEDICARE HOSPITAL INSURANCE PART B?",?70,"|8A. EFFECTIVE DATE (mm/dd/yyyy)"
- +23 WRITE !?3,@EASD@("14L"),?70,"| ",@EASD@("14L1")
- +24 WRITE ?131,$CHAR(13)
- if EALNE("ULC")="-"
- WRITE !
- WRITE EALNE("UL")
- +25 ;
- +26 WRITE !,"9. NAME EXACTLY AS IT APPEARS ON YOUR MEDICARE CARD",?70,"|10. MEDICARE CLAIM NUMBER"
- +27 WRITE !?3,@EASD@("14N"),?70,"| ",@EASD@("14M")
- +28 WRITE ?131,$CHAR(13)
- if EALNE("ULC")="-"
- WRITE !
- WRITE EALNE("UL")
- +29 QUIT
- +30 ;
- EI ; Print VA 10-10EZR SECTION III - EMPLOYMENT INFORMATION
- +1 ;
- +2 WRITE !?48,"SECTION III - EMPLOYMENT INFORMATION"
- +3 WRITE ?131,$CHAR(13)
- if EALNE("ULC")="-"
- WRITE !
- WRITE EALNE("UL")
- +4 ;
- +5 WRITE !,"1. VETERAN'S EMPLOYMENT STATUS",?47,"|1A. COMPANY NAME, ADDRESS AND TELEPHONE NUMBER"
- +6 WRITE !?3,$PIECE(@EASD@("15A"),U),?47,"| ",$PIECE(@EASD@("15B"),U)
- +7 WRITE !,"Date of retirement (mm/dd/yyyy) ",$PIECE(@EASD@("15A"),U,2),?47,"| ",$PIECE(@EASD@("15B"),U,2)
- +8 WRITE !,"If employed or retired, complete item 1A",?47,"| ",$PIECE(@EASD@("15B"),U,3)
- +9 WRITE !?47," ",$PIECE(@EASD@("15B"),U,4)
- +10 WRITE ?131,$CHAR(13)
- if EALNE("ULC")="-"
- WRITE !
- WRITE EALNE("UL")
- +11 ;
- +12 WRITE !,"2. SPOUSE'S EMPLOYMENT STATUS",?47,"|2A. COMPANY NAME, ADDRESS AND TELEPHONE NUMBER"
- +13 WRITE !?3,$PIECE(@EASD@("16A"),U),?47,"| ",$PIECE(@EASD@("16B"),U)
- +14 WRITE !,"Date of retirement (mm/dd/yyyy) ",$PIECE(@EASD@("16A"),U,2),?47,"| ",$PIECE(@EASD@("16B"),U,2)
- +15 WRITE !,"If employed or retired, complete item 2A",?47,"| ",$PIECE(@EASD@("16B"),U,3)
- +16 WRITE !?47,"| ",$PIECE(@EASD@("16B"),U,4)
- +17 WRITE ?131,$CHAR(13)
- if EALNE("ULC")="-"
- WRITE !
- WRITE EALNE("UL")
- +18 QUIT