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Routine: EASEZRP3

EASEZRP3.m

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  1. 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
  1.  ;
  1.  Q
  1.  ;
  1. EN(EALNE,EAINFO,EASDG) ; Entry point to print Page 3, called from EN^EASEZRPF
  1.  ;  Input
  1.  ;     EALNE  - Array of line formats for output
  1.  ;     EAINFO - Application Data array, see SETUP^EASEZRPF
  1.  ;     EASDG  - Flag variable to signify request to print from DG options
  1.  ;
  1.  N EASIGN,EASD
  1.  ;
  1.  I $$GET1^DIQ(712,EAINFO("EASAPP")_",",4)]"" D
  1.  . S EASIGN=$$GET1^DIQ(712,EAINFO("EASAPP")_",",4.1)
  1.  S EASIGN=$G(EASIGN)
  1.  ;
  1.  D HDR^EASEZRPF(.EALNE,.EAINFO)
  1.  S EASD=$NA(^TMP("EASEZR",$J,2))
  1.  ;
  1.  D NET
  1.  D PAP^EASEZRP2
  1.  D CON
  1.  D AOB
  1.  D FT^EASEZRPF(.EALNE,.EAINFO)
  1.  ;
  1.  Q
  1.  ;
  1. NET ;  Print SECTION VIII - PREVIOUS CALENDAR YEAR NET WORTH
  1.  ;
  1.  I $G(EASDG),+@EASD@(999) W !!?2,"SECTION VIII - PREVIOUS CALENDAR YEAR NET WORTH  (INCOME YEAR:  ",@EASD@(999),")  (Use a separate sheet for additional dependents)"
  1.  E  W !!?38,"SECTION VIII - PREVIOUS CALENDAR YEAR NET WORTH  (Use a separate sheet for additional dependents)"
  1.  W ?131,$C(13) W:EALNE("ULC")="-" ! W EALNE("UL")
  1.  ;
  1.  W !?78,"|",?84,"VETERAN",?96,"|",?102,"SPOUSE",?114,"|",?120,"CHILD 1"
  1.  W ?131,$C(13) W:EALNE("ULC")="-" ! W EALNE("UL")
  1.  ;
  1.  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,"|  $ ",$P(@EASD@("2E1"),U,3)
  1.  W !,"certificates of deposit, individual retirement accounts, stocks and bonds)",?78,"|",?96,"|",?114,"|"
  1.  W ?131,$C(13) W:EALNE("ULC")="-" ! W EALNE("UL")
  1.  ;
  1.  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,"|  $ ",$P(@EASD@("2E2"),U,3)
  1.  W !,"homes and non-income-producing property.  Do not include your primary home.)",?78,"|",?96,"|",?114,"|"
  1.  W ?131,$C(13) W:EALNE("ULC")="-" ! W EALNE("UL")
  1.  ;
  1.  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,"|  $ ",$P(@EASD@("2E3"),U,3)
  1.  W !,"MINUS THE AMOUNT YOU OWE ON THESE ITEMS.  INCLUDE VALUE OF FARM, RANCH, OR",?78,"|",?96,"|",?114,"|"
  1.  W !,"BUSINESS ASSETS.  Exclude household effects and family vehicles.",?78,"|",?96,"|",?114,"|"
  1.  W ?131,$C(13) W:EALNE("ULC")="-" ! W EALNE("UL")
  1.  Q
  1.  ;
  1. CON ;  Print SECTION X - CONSENT TO COPAYMENTS
  1.  ;
  1.  W !?49,"SECTION X - CONSENT TO COPAYMENTS"
  1.  W ?131,$C(13) W:EALNE("ULC")="-" ! W EALNE("UL")
  1.  ;
  1.  W !,"By signing this application you are agreeing to pay the applicable VA copays for treatment or services for your NSC conditions as"
  1.  W !,"required by law."
  1.  W ?131,$C(13) W:EALNE("ULC")="-" ! W EALNE("UL")
  1.  Q
  1.  ;
  1. AOB ;  Print SECTION XI - ASSIGNMENT OF BENEFITS
  1.  ;
  1.  W !?48,"SECTION XI - ASSIGNMENT OF BENEFITS"
  1.  W ?131,$C(13) W:EALNE("ULC")="-" ! W EALNE("UL")
  1.  ;
  1.  W !,"I understand that pursuant to 38 U.S.C. Section 1729 and 42 U.S.C. 2651, the Department of Veterans Affairs (VA) is authorized to"
  1.  W !,"recover or collect from my health plan (HP) or any other legally responsible third party for the reasonable charges of nonservice-"
  1.  W !,"connected VA medical care or services furnished or provided to me.  I hereby authorize payment directly to VA from any HP under"
  1.  W !,"which I am covered (including coverage provided under my spouse's HP) that is responsible for payment of the charges for my medical"
  1.  W !,"care, including benefits otherwise payable to me or my spouse.  Furthermore, I hereby assign to the VA any claim I may have against"
  1.  W !,"any person or entity who is or may be legally responsible for the payment of the cost of medical services provided to me by the VA."
  1.  W !,"I understand that this assignment shall not limit or prejudice my right to recover for my own benefit any amount in excess of the"
  1.  W !,"cost of medical services provided to me by the VA or any other amount to which I may be entitled.  I hereby appoint the Attorney"
  1.  W !,"General of the United States and the Secretary of Veterans' Affairs and their designees as my Attorneys-in-fact to take all"
  1.  W !,"necessary and appropriate actions in order to recover and receive all or part of the amount herein assigned.  I hereby authorize"
  1.  W !,"the VA to disclose to my attorney and to any third party or administrative agency who may be responsible for payment of the cost of"
  1.  W !,"medical services provided to me, information from my medical records as necessary to verify my claim.  Further, I hereby authorize"
  1.  W !,"any such third party or administrative agency to disclose to the VA any information regarding my claim."
  1.  W ?131,$C(13) W:EALNE("ULC")="-" ! W EALNE("UL")
  1.  ;
  1.  W !?11,"ALL APPLICANTS MUST SIGN AND DATE THIS FORM.  REFER TO INSTRUCTIONS ON WHO CAN SIGN ON BEHALF OF THE VETERAN.",!
  1.  W ?131,$C(13) W:EALNE("ULC")="-" ! W EALNE("UL")
  1.  ;
  1.  W !,"SIGNATURE OF APPLICANT",?90,"| DATE (mm/dd/yyyy)"
  1.  I $G(EASIGN)]"" W !,"SIGNATURE OF APPLICANT OR APPLICANT'S REPRESENTATIVE HAS BEEN VERIFIED",?90,"| ",EASIGN,!?90,"|"
  1.  E  W !?90,"|",!?90,"|"
  1.  W ?131,$C(13) W:EALNE("ULC")="-" ! W EALNE("UL")
  1.  Q