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 Dec 13, 2024@01:55:01 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
