EASEZRP3 ;ALB/AMA,TDM - Print 1010EZR, Cont. ; 1/19/13 5:10pm
;;1.0;ENROLLMENT APPLICATION SYSTEM;**57,70,107**;Mar 15, 2001;Build 32
;
Q
;
EN(EALNE,EAINFO,EASDG) ; Entry point to print Page 3, called from EN^EASEZRPF
; Input
; EALNE - Array of line formats for output
; EAINFO - Application Data array, see SETUP^EASEZRPF
; EASDG - Flag variable to signify request to print from DG options
;
N EASIGN,EASD
;
I $$GET1^DIQ(712,EAINFO("EASAPP")_",",4)]"" D
. S EASIGN=$$GET1^DIQ(712,EAINFO("EASAPP")_",",4.1)
S EASIGN=$G(EASIGN)
;
D HDR^EASEZRPF(.EALNE,.EAINFO)
S EASD=$NA(^TMP("EASEZR",$J,2))
;
D NET
D PAP^EASEZRP2
D CON
D AOB
D FT^EASEZRPF(.EALNE,.EAINFO)
;
Q
;
NET ; Print SECTION VIII - PREVIOUS CALENDAR YEAR NET WORTH
;
I $G(EASDG),+@EASD@(999) W !!?2,"SECTION VIII - PREVIOUS CALENDAR YEAR NET WORTH (INCOME YEAR: ",@EASD@(999),") (Use a separate sheet for additional dependents)"
E W !!?38,"SECTION VIII - PREVIOUS CALENDAR YEAR NET WORTH (Use a separate sheet for additional dependents)"
W ?131,$C(13) W:EALNE("ULC")="-" ! W EALNE("UL")
;
W !?78,"|",?84,"VETERAN",?96,"|",?102,"SPOUSE",?114,"|",?120,"CHILD 1"
W ?131,$C(13) W:EALNE("ULC")="-" ! W EALNE("UL")
;
W !,"1. CASH, AMOUNT IN BANK ACCOUNTS (e.g., checking and savings accounts,",?78,"| $ ",$P(@EASD@("2E1"),U),?96,"| $ ",$P(@EASD@("2E1"),U,2),?114,"| $ ",$P(@EASD@("2E1"),U,3)
W !,"certificates of deposit, individual retirement accounts, stocks and bonds)",?78,"|",?96,"|",?114,"|"
W ?131,$C(13) W:EALNE("ULC")="-" ! W EALNE("UL")
;
W !,"2. MARKET VALUE OF LAND AND BUILDINGS MINUS MORTGAGES AND LIENS (e.g., second",?78,"| $ ",$P(@EASD@("2E2"),U),?96,"| $ ",$P(@EASD@("2E2"),U,2),?114,"| $ ",$P(@EASD@("2E2"),U,3)
W !,"homes and non-income-producing property. Do not include your primary home.)",?78,"|",?96,"|",?114,"|"
W ?131,$C(13) W:EALNE("ULC")="-" ! W EALNE("UL")
;
W !,"3. VALUE OF OTHER PROPERTY OR ASSETS (e.g., art, rare coins, collectibles)",?78,"| $ ",$P(@EASD@("2E3"),U),?96,"| $ ",$P(@EASD@("2E3"),U,2),?114,"| $ ",$P(@EASD@("2E3"),U,3)
W !,"MINUS THE AMOUNT YOU OWE ON THESE ITEMS. INCLUDE VALUE OF FARM, RANCH, OR",?78,"|",?96,"|",?114,"|"
W !,"BUSINESS ASSETS. Exclude household effects and family vehicles.",?78,"|",?96,"|",?114,"|"
W ?131,$C(13) W:EALNE("ULC")="-" ! W EALNE("UL")
Q
;
CON ; Print SECTION X - CONSENT TO COPAYMENTS
;
W !?49,"SECTION X - CONSENT TO COPAYMENTS"
W ?131,$C(13) W:EALNE("ULC")="-" ! W EALNE("UL")
;
W !,"By signing this application you are agreeing to pay the applicable VA copays for treatment or services for your NSC conditions as"
W !,"required by law."
W ?131,$C(13) W:EALNE("ULC")="-" ! W EALNE("UL")
Q
;
AOB ; Print SECTION XI - ASSIGNMENT OF BENEFITS
;
W !?48,"SECTION XI - ASSIGNMENT OF BENEFITS"
W ?131,$C(13) W:EALNE("ULC")="-" ! W EALNE("UL")
;
W !,"I understand that pursuant to 38 U.S.C. Section 1729 and 42 U.S.C. 2651, the Department of Veterans Affairs (VA) is authorized to"
W !,"recover or collect from my health plan (HP) or any other legally responsible third party for the reasonable charges of nonservice-"
W !,"connected VA medical care or services furnished or provided to me. I hereby authorize payment directly to VA from any HP under"
W !,"which I am covered (including coverage provided under my spouse's HP) that is responsible for payment of the charges for my medical"
W !,"care, including benefits otherwise payable to me or my spouse. Furthermore, I hereby assign to the VA any claim I may have against"
W !,"any person or entity who is or may be legally responsible for the payment of the cost of medical services provided to me by the VA."
W !,"I understand that this assignment shall not limit or prejudice my right to recover for my own benefit any amount in excess of the"
W !,"cost of medical services provided to me by the VA or any other amount to which I may be entitled. I hereby appoint the Attorney"
W !,"General of the United States and the Secretary of Veterans' Affairs and their designees as my Attorneys-in-fact to take all"
W !,"necessary and appropriate actions in order to recover and receive all or part of the amount herein assigned. I hereby authorize"
W !,"the VA to disclose to my attorney and to any third party or administrative agency who may be responsible for payment of the cost of"
W !,"medical services provided to me, information from my medical records as necessary to verify my claim. Further, I hereby authorize"
W !,"any such third party or administrative agency to disclose to the VA any information regarding my claim."
W ?131,$C(13) W:EALNE("ULC")="-" ! W EALNE("UL")
;
W !?11,"ALL APPLICANTS MUST SIGN AND DATE THIS FORM. REFER TO INSTRUCTIONS ON WHO CAN SIGN ON BEHALF OF THE VETERAN.",!
W ?131,$C(13) W:EALNE("ULC")="-" ! W EALNE("UL")
;
W !,"SIGNATURE OF APPLICANT",?90,"| DATE (mm/dd/yyyy)"
I $G(EASIGN)]"" W !,"SIGNATURE OF APPLICANT OR APPLICANT'S REPRESENTATIVE HAS BEEN VERIFIED",?90,"| ",EASIGN,!?90,"|"
E W !?90,"|",!?90,"|"
W ?131,$C(13) W:EALNE("ULC")="-" ! W EALNE("UL")
Q
--- Routine Detail --- with STRUCTURED ROUTINE LISTING ---[H[J[2J[HEASEZRP3 5193 printed Sep 23, 2025@19:31:09 Page 2
EASEZRP3 ;ALB/AMA,TDM - Print 1010EZR, Cont. ; 1/19/13 5:10pm
+1 ;;1.0;ENROLLMENT APPLICATION SYSTEM;**57,70,107**;Mar 15, 2001;Build 32
+2 ;
+3 QUIT
+4 ;
EN(EALNE,EAINFO,EASDG) ; Entry point to print Page 3, called from EN^EASEZRPF
+1 ; Input
+2 ; EALNE - Array of line formats for output
+3 ; EAINFO - Application Data array, see SETUP^EASEZRPF
+4 ; EASDG - Flag variable to signify request to print from DG options
+5 ;
+6 NEW EASIGN,EASD
+7 ;
+8 IF $$GET1^DIQ(712,EAINFO("EASAPP")_",",4)]""
Begin DoDot:1
+9 SET EASIGN=$$GET1^DIQ(712,EAINFO("EASAPP")_",",4.1)
End DoDot:1
+10 SET EASIGN=$GET(EASIGN)
+11 ;
+12 DO HDR^EASEZRPF(.EALNE,.EAINFO)
+13 SET EASD=$NAME(^TMP("EASEZR",$JOB,2))
+14 ;
+15 DO NET
+16 DO PAP^EASEZRP2
+17 DO CON
+18 DO AOB
+19 DO FT^EASEZRPF(.EALNE,.EAINFO)
+20 ;
+21 QUIT
+22 ;
NET ; Print SECTION VIII - PREVIOUS CALENDAR YEAR NET WORTH
+1 ;
+2 IF $GET(EASDG)
IF +@EASD@(999)
WRITE !!?2,"SECTION VIII - PREVIOUS CALENDAR YEAR NET WORTH (INCOME YEAR: ",@EASD@(999),") (Use a separate sheet for additional dependents)"
+3 IF '$TEST
WRITE !!?38,"SECTION VIII - PREVIOUS CALENDAR YEAR NET WORTH (Use a separate sheet for additional dependents)"
+4 WRITE ?131,$CHAR(13)
if EALNE("ULC")="-"
WRITE !
WRITE EALNE("UL")
+5 ;
+6 WRITE !?78,"|",?84,"VETERAN",?96,"|",?102,"SPOUSE",?114,"|",?120,"CHILD 1"
+7 WRITE ?131,$CHAR(13)
if EALNE("ULC")="-"
WRITE !
WRITE EALNE("UL")
+8 ;
+9 WRITE !,"1. CASH, AMOUNT IN BANK ACCOUNTS (e.g., checking and savings accounts,",?78,"| $ ",$PIECE(@EASD@("2E1"),U),?96,"| $ ",$PIECE(@EASD@("2E1"),U,2),?114,"| $ ",$PIECE(@EASD@("2E1"),U,3)
+10 WRITE !,"certificates of deposit, individual retirement accounts, stocks and bonds)",?78,"|",?96,"|",?114,"|"
+11 WRITE ?131,$CHAR(13)
if EALNE("ULC")="-"
WRITE !
WRITE EALNE("UL")
+12 ;
+13 WRITE !,"2. MARKET VALUE OF LAND AND BUILDINGS MINUS MORTGAGES AND LIENS (e.g., second",?78,"| $ ",$PIECE(@EASD@("2E2"),U),?96,"| $ ",$PIECE(@EASD@("2E2"),U,2),?114,"| $ ",$PIECE(@EASD@("2E2"),U,3)
+14 WRITE !,"homes and non-income-producing property. Do not include your primary home.)",?78,"|",?96,"|",?114,"|"
+15 WRITE ?131,$CHAR(13)
if EALNE("ULC")="-"
WRITE !
WRITE EALNE("UL")
+16 ;
+17 WRITE !,"3. VALUE OF OTHER PROPERTY OR ASSETS (e.g., art, rare coins, collectibles)",?78,"| $ ",$PIECE(@EASD@("2E3"),U),?96,"| $ ",$PIECE(@EASD@("2E3"),U,2),?114,"| $ ",$PIECE(@EASD@("2E3"),U,3)
+18 WRITE !,"MINUS THE AMOUNT YOU OWE ON THESE ITEMS. INCLUDE VALUE OF FARM, RANCH, OR",?78,"|",?96,"|",?114,"|"
+19 WRITE !,"BUSINESS ASSETS. Exclude household effects and family vehicles.",?78,"|",?96,"|",?114,"|"
+20 WRITE ?131,$CHAR(13)
if EALNE("ULC")="-"
WRITE !
WRITE EALNE("UL")
+21 QUIT
+22 ;
CON ; Print SECTION X - CONSENT TO COPAYMENTS
+1 ;
+2 WRITE !?49,"SECTION X - CONSENT TO COPAYMENTS"
+3 WRITE ?131,$CHAR(13)
if EALNE("ULC")="-"
WRITE !
WRITE EALNE("UL")
+4 ;
+5 WRITE !,"By signing this application you are agreeing to pay the applicable VA copays for treatment or services for your NSC conditions as"
+6 WRITE !,"required by law."
+7 WRITE ?131,$CHAR(13)
if EALNE("ULC")="-"
WRITE !
WRITE EALNE("UL")
+8 QUIT
+9 ;
AOB ; Print SECTION XI - ASSIGNMENT OF BENEFITS
+1 ;
+2 WRITE !?48,"SECTION XI - ASSIGNMENT OF BENEFITS"
+3 WRITE ?131,$CHAR(13)
if EALNE("ULC")="-"
WRITE !
WRITE EALNE("UL")
+4 ;
+5 WRITE !,"I understand that pursuant to 38 U.S.C. Section 1729 and 42 U.S.C. 2651, the Department of Veterans Affairs (VA) is authorized to"
+6 WRITE !,"recover or collect from my health plan (HP) or any other legally responsible third party for the reasonable charges of nonservice-"
+7 WRITE !,"connected VA medical care or services furnished or provided to me. I hereby authorize payment directly to VA from any HP under"
+8 WRITE !,"which I am covered (including coverage provided under my spouse's HP) that is responsible for payment of the charges for my medical"
+9 WRITE !,"care, including benefits otherwise payable to me or my spouse. Furthermore, I hereby assign to the VA any claim I may have against"
+10 WRITE !,"any person or entity who is or may be legally responsible for the payment of the cost of medical services provided to me by the VA."
+11 WRITE !,"I understand that this assignment shall not limit or prejudice my right to recover for my own benefit any amount in excess of the"
+12 WRITE !,"cost of medical services provided to me by the VA or any other amount to which I may be entitled. I hereby appoint the Attorney"
+13 WRITE !,"General of the United States and the Secretary of Veterans' Affairs and their designees as my Attorneys-in-fact to take all"
+14 WRITE !,"necessary and appropriate actions in order to recover and receive all or part of the amount herein assigned. I hereby authorize"
+15 WRITE !,"the VA to disclose to my attorney and to any third party or administrative agency who may be responsible for payment of the cost of"
+16 WRITE !,"medical services provided to me, information from my medical records as necessary to verify my claim. Further, I hereby authorize"
+17 WRITE !,"any such third party or administrative agency to disclose to the VA any information regarding my claim."
+18 WRITE ?131,$CHAR(13)
if EALNE("ULC")="-"
WRITE !
WRITE EALNE("UL")
+19 ;
+20 WRITE !?11,"ALL APPLICANTS MUST SIGN AND DATE THIS FORM. REFER TO INSTRUCTIONS ON WHO CAN SIGN ON BEHALF OF THE VETERAN.",!
+21 WRITE ?131,$CHAR(13)
if EALNE("ULC")="-"
WRITE !
WRITE EALNE("UL")
+22 ;
+23 WRITE !,"SIGNATURE OF APPLICANT",?90,"| DATE (mm/dd/yyyy)"
+24 IF $GET(EASIGN)]""
WRITE !,"SIGNATURE OF APPLICANT OR APPLICANT'S REPRESENTATIVE HAS BEEN VERIFIED",?90,"| ",EASIGN,!?90,"|"
+25 IF '$TEST
WRITE !?90,"|",!?90,"|"
+26 WRITE ?131,$CHAR(13)
if EALNE("ULC")="-"
WRITE !
WRITE EALNE("UL")
+27 QUIT
