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Routine: EASEZRP1

EASEZRP1.m

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  1. 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
  1. ;
  1. EN(EALNE,EAINFO) ;Entry point for VA 10-10EZR, page 1
  1. ; Called from EN^EASEZRPF
  1. N EASD,X
  1. ;
  1. S EASD=$NA(^TMP("EASEZR",$J,1))
  1. D HDRMAIN^EASEZRPF(.EALNE)
  1. D DEM
  1. D II
  1. D EI
  1. D FD^EASEZRP2
  1. ;
  1. D FT^EASEZRPF(.EALNE,.EAINFO)
  1. S EAINFO("VET")=@EASD@(2),EAINFO("SSN")=@EASD@(5)
  1. Q
  1. ;
  1. DEM ; Print VA 10-10EZR Section I, Demographic information
  1. ;
  1. W !?50,"SECTION I - GENERAL INFORMATION"
  1. W ?131,$C(13) W:EALNE("ULC")="-" ! W EALNE("UL")
  1. W !?18,"Federal law provides criminal penalties, including a fine and/or imprisonment for up to 5 years,"
  1. W !?20,"for concealing a material fact or making a materially false statement. (See 18 U.S.C. 1001)"
  1. W ?131,$C(13) W:EALNE("ULC")="-" ! W EALNE("UL")
  1. ;
  1. W !,"1. VETERAN'S NAME (Last, First, Middle Name)",?95,"|2. OTHER NAMES USED"
  1. W !?3,@EASD@(2),?95,"| ",@EASD@(3)
  1. W ?131,$C(13) W:EALNE("ULC")="-" ! W EALNE("UL")
  1. ;
  1. W !,"3. GENDER",?20,"|4. SOCIAL SECURITY NUMBER",?95,"|5. DATE OF BIRTH (mm/dd/yyyy)"
  1. W !?3,@EASD@(4),?20,"| ",@EASD@(5),?95,"| ",@EASD@(7)
  1. W ?131,$C(13) W:EALNE("ULC")="-" ! W EALNE("UL")
  1. ;
  1. ;EAS*1.0*70 - CHECK FOR FOREIGN ADDRESS
  1. I $G(@EASD@("9H"))="UNITED STATES" D I 1 ;Use domestic address field labels
  1. . W !,"6. PERMANENT ADDRESS (Street)",?46,"|6A. CITY",?85,"|6B. STATE",?105,"|6C. ZIP"
  1. . W !?3,@EASD@("9A"),?46,"| ",@EASD@("9B"),?85,"| ",@EASD@("9C"),?105,"| ",@EASD@("9D")
  1. . W ?131,$C(13) W:EALNE("ULC")="-" ! W EALNE("UL")
  1. . ;
  1. . W !,"6D. COUNTY",?66,"|6E. HOME TELEPHONE NUMBER (Include area code)"
  1. . W !?4,@EASD@("9E"),?66,"| ",@EASD@(10)
  1. ;
  1. E D ;Use foreign address field labels
  1. . W !,"6. PERMANENT ADDRESS (Street)",?46,"|6A. CITY",?85,"|6B. PROVINCE",?105,"|6C. POSTAL CODE"
  1. . W !?3,@EASD@("9A"),?46,"| ",@EASD@("9B"),?85,"| ",@EASD@("9F"),?105,"| ",@EASD@("9G")
  1. . W ?131,$C(13) W:EALNE("ULC")="-" ! W EALNE("UL")
  1. . ;
  1. . W !,"6D. COUNTRY",?66,"|6E. HOME TELEPHONE NUMBER (Include area code)"
  1. . W !?4,@EASD@("9H"),?34,"| ",@EASD@(10)
  1. W ?131,$C(13) W:EALNE("ULC")="-" ! W EALNE("UL")
  1. W !,"6F. E-MAIL ADDRESS",?66,"|6G. CELLULAR TELEPHONE NUMBER (Include area code)"
  1. W !,?4,@EASD@("11A"),?66,"| ",@EASD@("11G")
  1. ;
  1. W ?131,$C(13) W:EALNE("ULC")="-" ! W EALNE("UL")
  1. ;
  1. W !,"7. CURRENT MARITAL STATUS"
  1. W !,?3,@EASD@(12)
  1. W ?131,$C(13) W:EALNE("ULC")="-" ! W EALNE("UL")
  1. ;
  1. W !,"8. NAME, ADDRESS AND RELATIONSHIP OF NEXT OF KIN",?83,"|8A. NEXT OF KIN'S HOME TELEPHONE NUMBER"
  1. W !?3,$P(@EASD@("19A"),U)," - ",$P(@EASD@("19A"),U,4),?83,"| (Include area code) ",@EASD@("19B")
  1. W ?131,$C(13) W:EALNE("ULC")="-" ! F X=1:1:84 W " "
  1. W $E(EALNE("UL"),1,48)
  1. W !?3,$P(@EASD@("19A"),U,2),?83,"|8B. NEXT OF KIN'S WORK TELEPHONE NUMBER"
  1. W !?3,$P(@EASD@("19A"),U,3),?83,"| (Include area code) ",@EASD@("19C")
  1. W ?131,$C(13) W:EALNE("ULC")="-" ! W EALNE("UL")
  1. ;
  1. W !,"9. NAME, ADDRESS AND RELATIONSHIP OF EMERGENCY CONTACT",?83,"|9A. EMERGENCY CONTACT'S HOME TELEPHONE NUMBER"
  1. W !?3,$P(@EASD@("20A"),U)," - ",$P(@EASD@("20A"),U,4),?83,"| (Include area code) ",@EASD@("20B")
  1. W ?131,$C(13) W:EALNE("ULC")="-" ! F X=1:1:84 W " "
  1. W $E(EALNE("UL"),1,48)
  1. W !?3,$P(@EASD@("20A"),U,2),?83,"|9B. EMERGENCY CONTACT'S WORK TELEPHONE NUMBER"
  1. W !?3,$P(@EASD@("20A"),U,3),?83,"| (Include area code) ",@EASD@("20C")
  1. W ?131,$C(13) W:EALNE("ULC")="-" ! W EALNE("UL")
  1. ;
  1. ;W !,"10. INDIVIDUAL TO RECEIVE POSSESSION OF YOUR PERSONAL PROPERTY LEFT ON PREMISES UNDER VA CONTROL AFTER YOUR DEPARTURE OR AT THE"
  1. ;W !?4,"TIME OF DEATH. Note: This does not constitute a will or transfer of title. ",@EASD@(21)
  1. ;W ?131,$C(13) W:EALNE("ULC")="-" ! W EALNE("UL")
  1. Q
  1. ;
  1. II ; Print VA 10-10EZR SECTION II - INSURANCE INFORMATION
  1. ;
  1. W !?23,"SECTION II - INSURANCE INFORMATION (Use a separate sheet for additional information)"
  1. W ?131,$C(13) W:EALNE("ULC")="-" ! W EALNE("UL")
  1. ;
  1. W !,"1. ARE YOU COVERED BY HEALTH INSURANCE,",?49,"|2. HEALTH INSURANCE COMPANY NAME, ADDRESS AND TELEPHONE NUMBER"
  1. W !?3,"INCLUDING COVERAGE THROUGH A SPOUSE",?49,"| ",@EASD@("17A")
  1. W !?3,"OR ANOTHER PERSON? ",@EASD@(17),?49,"| "
  1. W ?131,$C(13) W:EALNE("ULC")="-" ! W $E(EALNE("UL"),1,49)
  1. ;
  1. W !,"3. NAME OF POLICY HOLDER",?49,"| ",$P(@EASD@("17E"),U,2)
  1. W !?3,@EASD@("17B"),?49,"| ",@EASD@("17I")
  1. W ?131,$C(13) W:EALNE("ULC")="-" ! W EALNE("UL")
  1. ;
  1. W !,"4. POLICY NUMBER",?41,"|5. GROUP CODE",?70,"|6. ARE YOU ELIGIBLE FOR MEDICAID?",?111,"|6A. EFFECTIVE DATE"
  1. W !?3,@EASD@("17C"),?41,"| ",@EASD@("17D"),?70,"| ",@EASD@("14J"),?111,"| "
  1. W ?131,$C(13) W:EALNE("ULC")="-" ! W EALNE("UL")
  1. ;
  1. W !,"7. ARE YOU ENROLLED IN MEDICARE HOSPITAL INSURANCE PART A?",?70,"|7A. EFFECTIVE DATE (mm/dd/yyyy)"
  1. W !?3,@EASD@("14K"),?70,"| ",@EASD@("14K1")
  1. W ?131,$C(13) W:EALNE("ULC")="-" ! W EALNE("UL")
  1. ;
  1. W !,"8. ARE YOU ENROLLED IN MEDICARE HOSPITAL INSURANCE PART B?",?70,"|8A. EFFECTIVE DATE (mm/dd/yyyy)"
  1. W !?3,@EASD@("14L"),?70,"| ",@EASD@("14L1")
  1. W ?131,$C(13) W:EALNE("ULC")="-" ! W EALNE("UL")
  1. ;
  1. W !,"9. NAME EXACTLY AS IT APPEARS ON YOUR MEDICARE CARD",?70,"|10. MEDICARE CLAIM NUMBER"
  1. W !?3,@EASD@("14N"),?70,"| ",@EASD@("14M")
  1. W ?131,$C(13) W:EALNE("ULC")="-" ! W EALNE("UL")
  1. Q
  1. ;
  1. EI ; Print VA 10-10EZR SECTION III - EMPLOYMENT INFORMATION
  1. ;
  1. W !?48,"SECTION III - EMPLOYMENT INFORMATION"
  1. W ?131,$C(13) W:EALNE("ULC")="-" ! W EALNE("UL")
  1. ;
  1. W !,"1. VETERAN'S EMPLOYMENT STATUS",?47,"|1A. COMPANY NAME, ADDRESS AND TELEPHONE NUMBER"
  1. W !?3,$P(@EASD@("15A"),U),?47,"| ",$P(@EASD@("15B"),U)
  1. W !,"Date of retirement (mm/dd/yyyy) ",$P(@EASD@("15A"),U,2),?47,"| ",$P(@EASD@("15B"),U,2)
  1. W !,"If employed or retired, complete item 1A",?47,"| ",$P(@EASD@("15B"),U,3)
  1. W !?47," ",$P(@EASD@("15B"),U,4)
  1. W ?131,$C(13) W:EALNE("ULC")="-" ! W EALNE("UL")
  1. ;
  1. W !,"2. SPOUSE'S EMPLOYMENT STATUS",?47,"|2A. COMPANY NAME, ADDRESS AND TELEPHONE NUMBER"
  1. W !?3,$P(@EASD@("16A"),U),?47,"| ",$P(@EASD@("16B"),U)
  1. W !,"Date of retirement (mm/dd/yyyy) ",$P(@EASD@("16A"),U,2),?47,"| ",$P(@EASD@("16B"),U,2)
  1. W !,"If employed or retired, complete item 2A",?47,"| ",$P(@EASD@("16B"),U,3)
  1. W !?47,"| ",$P(@EASD@("16B"),U,4)
  1. W ?131,$C(13) W:EALNE("ULC")="-" ! W EALNE("UL")
  1. Q