{"aaData": [["UNKNOWN", "UNKNOWN\n", "ACTIVE\n", "", "1.0\n", "", "0\n", "0\n", "0\n", "", ""], ["TYPE OF BENEFIT-HEALTH SERVICES", "I;1A.1\n", "ACTIVE\n", "", "1.0\n", "S EASRTR=$$YN^EASEZT1(EZDATA)\n", "0\n", "0\n", "0\n", "Applying for Health Services\n", "S DIR(0)=\"S^Y:YES;N:NO\"\n"], ["APPLICANT SUFFIX NAME", "I;2.4\n", "ACTIVE\n", "", "1.0\n", "", "2\n", "2\n", ".01\n", "", "S DIR(0)=\"FO^1:6^K:X'?1.A X\"\n"], ["E-CONTACT ZIP", "I;20A.6\n", "ACTIVE\n", "", "1.0\n", "S EASRTR=$$ZIP^EASEZT2(EZDATA)\n", "2\n", "2\n", ".2201\n", "E-Cont. Zip\n", "S DIR(0)=\"FO^5:10^S XX=$TR(X,\"\"-\"\",\"\"\"\") I XX'?5N,(XX'?9N) K X\"\n"], ["E-CONTACT RELATIONSHIP", "I;20A.7\n", "ACTIVE\n", "", "1.0\n", "S EASRTR=$$UC^EASEZT1(EZDATA)\n", "2\n", "2\n", ".332\n", "E-Cont. Relationship\n", "S DIR(0)=\"S^1:SELF;2:SPOUSE;3:SON;4:DAUGHTER;5:FATHER;6:MOTHER;99:OTHER\"\n"], ["E-CONTACT HOME PHONE AREA CODE", "I;20B.1\n", "ACTIVE\n", "", "1.0\n", "S EASRTR=$$HOMEPH^EASEZT2(EASAPP,\"E-CONTACT\")\n", "2\n", "2\n", ".339\n", "E-Cont. Home Phone\n", "S DIR(0)=\"FO^3:3^K:X'?3N X\"\n"], ["E-CONTACT HOME PHONE NUMBER", "I;20B.2\n", "ACTIVE\n", "", "1.0\n", "", "2\n", "2\n", ".339\n", "E-Cont. Home Phone\n", "S DIR(0)=\"FO^8:8^K:X'?3N1\"\"-\"\"4N X\"\n"], ["E-CONTACT WORK PHONE AREA CODE", "I;20C.1\n", "ACTIVE\n", "", "1.0\n", "S EASRTR=$$WORKPH^EASEZT2(EASAPP,\"E-CONTACT\")\n", "2\n", "2\n", ".33011\n", "E-Cont. Work Number\n", "S DIR(0)=\"FO^3:3^K:X'?3N X\"\n"], ["E-CONTACT WORK PHONE NUMBER", "I;20C.2\n", "ACTIVE\n", "", "1.0\n", "", "2\n", "2\n", ".33011\n", "E-Cont. Work Phone\n", "S DIR(0)=\"FO^8:8^K:X'?3N1\"\"-\"\"4N X\"\n"], ["E-CONTACT WORK PHONE EXTENSION", "I;20C.3\n", "ACTIVE\n", "", "1.0\n", "", "2\n", "2\n", ".33011\n", "E-Cont. Work Ext.\n", "S DIR(0)=\"FO^1:5^K:X'?1.N X\"\n"], ["DESIGNEE", "I;21.\n", "ACTIVE\n", "", "1.0\n", "", "2\n", "2\n", ".3405\n", "Designee\n", "S DIR(0)=\"SM^N:NEXT OF KIN;E:EMERGENCY CONTACT\"\n"], ["NEED RELATED TO JOB INJURY", "I;22A.\n", "ACTIVE\n", "", "1.0\n", "S EASRTR=$$YN^EASEZT1(EZDATA)\n", "0\n", "0\n", "0\n", "Need Due to Job Inj.?\n", ""], ["NEED RELATED TO ACCIDENT", "I;22B.\n", "ACTIVE\n", "", "1.0\n", "S EASRTR=$$YN^EASEZT1(EZDATA)\n", "0\n", "0\n", "0\n", "Need Due to Accid.?\n", ""], ["APPLICANT OTHER NAME", "I;3.\n", "ACTIVE\n", "", "1.0\n", "S EASRTR=$$UC^EASEZT1(EZDATA)\n", "2\n", "2.01\n", ".01\n", "Alias\n", "S DIR(0)=\"FO^2:30\"\n"], ["SPOUSE LAST NAME", "IIA;1.1\n", "ACTIVE\n", "", "1.0\n", "S EASRTR=$$NAME^EASEZT1(EASAPP,\"SPOUSE\",EASMULT)\n", "408.13\n", "408.13\n", ".01\n", "Sp. Name\n", "S DIR(0)=\"FO^1:50^I X'?1.A,X'?1.A1\"\"-\"\"1.A,X'?1.A1\"\" \"\"1.A K X\"\n"], ["SPOUSE FIRST NAME", "IIA;1.2\n", "ACTIVE\n", "", "1.0\n", "", "408.13\n", "408.13\n", ".01\n", "Sp. First Name\n", "S DIR(0)=\"FO^1:25^I X'?1.A,X'?1.A1\"\"-\"\"1.A,X'?1.A1\"\" \"\"1.A K X\"\n"], ["SPOUSE MIDDLE NAME", "IIA;1.3\n", "ACTIVE\n", "", "1.0\n", "", "408.13\n", "408.13\n", ".01\n", "", "S DIR(0)=\"FO^1:25^I X'?1.A,X'?1.A1\"\"-\"\"1.A,X'?1.A1\"\" \"\"1.A K X\"\n"], ["SPOUSE SUFFIX NAME", "IIA;1.4\n", "ACTIVE\n", "", "1.0\n", "", "408.13\n", "408.13\n", ".01\n", "", "S DIR(0)=\"FO^1:6^K:X'?1.A X\"\n"], ["CHILD1 LAST NAME", "IIA;2.1\n", "ACTIVE\n", "", "1.0\n", "S EASRTR=$$NAME^EASEZT1(EASAPP,\"CHILD1\",EASMULT)\n", "408.13\n", "408.13\n", ".01\n", "Child Name\n", "S DIR(0)=\"FO^1:50^I X'?1.A,X'?1.A1\"\"-\"\"1.A,X'?1.A1\"\" \"\"1.A K X\"\n"], ["CHILD1 FIRST NAME", "IIA;2.2\n", "ACTIVE\n", "", "1.0\n", "", "408.13\n", "408.13\n", ".01\n", "", "S DIR(0)=\"FO^1:25^I X'?1.A,X'?1.A1\"\"-\"\"1.A,X'?1.A1\"\" \"\"1.A K X\"\n"], ["CHILD1 MIDDLE NAME", "IIA;2.3\n", "ACTIVE\n", "", "1.0\n", "", "408.13\n", "408.13\n", ".01\n", "", "S DIR(0)=\"FO^1:25^I X'?1.A,X'?1.A1\"\"-\"\"1.A,X'?1.A1\"\" \"\"1.A K X\"\n"], ["CHILD1 SUFFIX NAME", "IIA;2.4\n", "ACTIVE\n", "", "1.0\n", "", "408.13\n", "408.13\n", ".01\n", "", "S DIR(0)=\"FO^1:6^K:X'?1.A X\"\n"], ["SPOUSE SOCIAL SECURITY NUMBER", "IIA;3.\n", "ACTIVE\n", "", "1.0\n", "S EASRTR=$$SSNOUT^EASEZT1(EZDATA)\n", "408.13\n", "408.13\n", ".09\n", "Sp. SSN\n", "S DIR(0)=\"F^11:11^K:X'?3N1\"\"-\"\"2N1\"\"-\"\"4N X\",DIR(\"?\")=\"Use format nnn-nnn-nnn. Example: 222-33-4444\"\n"], ["SPOUSE DATE OF BIRTH", "IIA;4.\n", "ACTIVE\n", "", "1.0\n", "S EASRTR=$$XDATE^EASEZT1(EZDATA)\n", "408.13\n", "408.13\n", ".03\n", "Sp. DOB\n", ""], ["APPLICANT SEX", "I;4.\n", "ACTIVE\n", "", "1.0\n", "S EASRTR=$$SEX^EASEZT1(EZDATA)\n", "2\n", "2\n", ".02\n", "Sex\n", ""], ["CHILD1 DATE OF BIRTH", "IIA;5.\n", "ACTIVE\n", "", "1.0\n", "S EASRTR=$$XDATE^EASEZT1(EZDATA)\n", "408.13\n", "408.13\n", ".03\n", "Child DOB\n", ""], ["SPOUSE STREET", "IIA;6.1\n", "ACTIVE\n", "", "2.5\n", "S EASRTR=$$UC^EASEZT1(EZDATA)\n", "408.13\n", "408.13\n", "1.2\n", "Sp. Street Addr.\n", "S DIR(0)=\"F^3:35\"\n"], ["SPOUSE CITY", "IIA;6.2\n", "ACTIVE\n", "", "2.5\n", "S EASRTR=$$UC^EASEZT1(EZDATA)\n", "408.13\n", "408.13\n", "1.5\n", "Sp. City\n", "S DIR(0)=\"F^2:15\"\n"], ["SPOUSE STATE", "IIA;6.3\n", "ACTIVE\n", "", "2.5\n", "S EASRTR=$$STATE^EASEZT1(EZDATA)\n", "408.13\n", "408.13\n", "1.6\n", "Sp. State\n", ""], ["SPOUSE ZIP", "IIA;6.4\n", "ACTIVE\n", "", "2.5\n", "S EASRTR=$$ZIP^EASEZT2(EZDATA)\n", "408.13\n", "408.13\n", "1.7\n", "Sp. Zip\n", "S DIR(0)=\"FO^5:10^S XX=$TR(X,\"\"-\"\",\"\"\"\") I XX'?5N,(XX'?9N) K X\"\n"], ["CHILD1 SOCIAL SECURITY NUMBER", "IIA;7.\n", "ACTIVE\n", "", "1.0\n", "S EASRTR=$$SSNOUT^EASEZT1(EZDATA)\n", "408.13\n", "408.13\n", ".09\n", "Child SSN\n", "S DIR(0)=\"F^11:11^K:X'?3N1\"\"-\"\"2N1\"\"-\"\"4N X\",DIR(\"?\")=\"Use format nnn-nnn-nnn. Example: 222-33-4444\"\n"], ["SPOUSE HOME PHONE AREA CODE", "IIA;8.1\n", "ACTIVE\n", "", "2.5\n", "S EASRTR=$$HOMEPH^EASEZT2(EASAPP,\"SPOUSE\")\n", "408.13\n", "408.13\n", "1.8\n", "Sp. Home Phone\n", "S DIR(0)=\"FO^3:3^K:X'?3N X\"\n"], ["SPOUSE HOME PHONE NUMBER", "IIA;8.2\n", "ACTIVE\n", "", "2.5\n", "", "408.13\n", "408.13\n", "1.8\n", "Sp. Home Phone\n", "S DIR(0)=\"FO^8:8^K:X'?3N1\"\"-\"\"4N X\"\n"], ["CHILD1 RELATIONSHIP", "IIA;9.\n", "ACTIVE\n", "", "1.0\n", "S EASRTR=$$UC^EASEZT1(EZDATA)\n", "408.12\n", "408.12\n", ".02\n", "Child Relationship\n", ""], ["DATE OF MARRIAGE TO SPOUSE", "IIA;10.\n", "ACTIVE\n", "", "1.0\n", "S EASRTR=$$XDATE^EASEZT1(EZDATA)\n", "408.12\n", "408.1275\n", ".01\n", "Sp. Effective Date\n", ""], ["APPLICANT SOCIAL SECURITY NUMBER", "I;5.\n", "ACTIVE\n", "", "1.0\n", "", "2\n", "2\n", ".09\n", "SSN\n", "S DIR(0)=\"F^11:11^K:X'?3N1\"\"-\"\"2N1\"\"-\"\"4N X\",DIR(\"?\")=\"Use format nnn-nnn-nnn. Example: 222-33-4444\"\n"], ["DATE CHILD1 BECAME DEPENDENT", "IIA;11.\n", "ACTIVE\n", "", "1.0\n", "S EASRTR=$$XDATE^EASEZT1(EZDATA)\n", "408.12\n", "408.1275\n", ".01\n", "Child Effective Date\n", ""], ["AMOUNT CONTRIBUTED TO SP", "IIA;12.1\n", "ACTIVE\n", "", "1.0\n", "", "408.22\n", "408.22\n", ".07\n", "Amt To Sp. Support\n", "D H07^EASEZDD\n"], ["AMOUNT CONTRIBUTED TO CHILD1", "IIA;12.2\n", "ACTIVE\n", "", "1.0\n", "", "408.22\n", "408.22\n", ".19\n", "Amt To Child Support\n", "D H19^EASEZDD\n"], ["CHILD1 EDUCATION EXPENSES", "IIA;13.\n", "ACTIVE\n", "", "1.0\n", "", "408.21\n", "408.21\n", "1.03\n", "Ed. $ Paid by Child\n", ""], ["CHILD1 PERMANENTLY DISABLED", "IIA;14.\n", "ACTIVE\n", "", "1.0\n", "S EASRTR=$$YN^EASEZT1(EZDATA)\n", "408.22\n", "408.22\n", ".09\n", "Child Perm. Disab.?\n", ""], ["CHILD1 18-23 IN SCHOOL", "IIA;15.\n", "ACTIVE\n", "", "2.5\n", "S EASRTR=$$YN^EASEZT1(EZDATA)\n", "408.22\n", "408.22\n", ".18\n", "Age 18-23 in School?\n", "D H18^EASEZDD\n"], ["CHILD(N) LAST NAME", "IIB;1.1\n", "ACTIVE\n", "", "1.0\n", "S EASRTR=$$NAME^EASEZT1(EASAPP,\"CHILD(N)\",EASMULT)\n", "408.13\n", "408.13\n", ".01\n", "Child Name\n", "S DIR(0)=\"FO^1:50^I X'?1.A,X'?1.A1\"\"-\"\"1.A,X'?1.A1\"\" \"\"1.A K X\"\n"], ["CHILD(N) FIRST NAME", "IIB;1.2\n", "ACTIVE\n", "", "1.0\n", "", "408.13\n", "408.13\n", ".01\n", "", "S DIR(0)=\"FO^1:25^I X'?1.A,X'?1.A1\"\"-\"\"1.A,X'?1.A1\"\" \"\"1.A K X\"\n"], ["CHILD(N) MIDDLE NAME", "IIB;1.3\n", "ACTIVE\n", "", "1.0\n", "", "408.13\n", "408.13\n", ".01\n", "", "S DIR(0)=\"FO^1:25^I X'?1.A,X'?1.A1\"\"-\"\"1.A,X'?1.A1\"\" \"\"1.A K X\"\n"], ["CHILD(N) SUFFIX NAME", "IIB;1.4\n", "ACTIVE\n", "", "1.0\n", "", "408.13\n", "408.13\n", ".01\n", "", "S DIR(0)=\"FO^1:6^K:X'?1.A X\"\n"], ["APPLICANT CLAIM NUMBER", "I;6.\n", "ACTIVE\n", "", "1.0\n", "", "2\n", "2\n", ".313\n", "Claim #\n", ""], ["CHILD(N) SOCIAL SECURITY NUMBER", "IIB;2.\n", "ACTIVE\n", "", "1.0\n", "S EASRTR=$$SSNOUT^EASEZT1(EZDATA)\n", "408.13\n", "408.13\n", ".09\n", "Child SSN\n", "S DIR(0)=\"F^11:11^K:X'?3N1\"\"-\"\"2N1\"\"-\"\"4N X\",DIR(\"?\")=\"Use format nnn-nnn-nnn. Example: 222-33-4444\"\n"], ["CHILD(N) DATE OF BIRTH", "IIB;3.\n", "ACTIVE\n", "", "1.0\n", "S EASRTR=$$XDATE^EASEZT1(EZDATA)\n", "408.13\n", "408.13\n", ".03\n", "Child DOB\n", ""], ["CHILD(N) RELATIONSHIP", "IIB;4.\n", "ACTIVE\n", "", "1.0\n", "S EASRTR=$$UC^EASEZT1(EZDATA)\n", "408.12\n", "408.12\n", ".02\n", "Child Relationship\n", ""], ["DATE CHILD(N) BECAME DEPENDENT", "IIB;5.\n", "ACTIVE\n", "", "1.0\n", "S EASRTR=$$XDATE^EASEZT1(EZDATA)\n", "408.12\n", "408.1275\n", ".01\n", "Child Effective Date\n", ""], ["AMOUNT CONTRIBUTED TO CHILD(N)", "IIB;6.\n", "ACTIVE\n", "", "3.0\n", "", "408.22\n", "408.22\n", ".19\n", "Amt To Child Support\n", "D H19^EASEZDD\n"], ["CHILD(N) EDUCATION EXPENSES", "IIB;7.\n", "ACTIVE\n", "", "1.0\n", "", "408.21\n", "408.21\n", "1.03\n", "Ed. $ Paid by Child\n", ""], ["CHILD(N) PERMANENTLY DISABLED", "IIB;8.\n", "ACTIVE\n", "", "1.0\n", "S EASRTR=$$YN^EASEZT1(EZDATA)\n", "408.22\n", "408.22\n", ".09\n", "Child Perm. Disab.?\n", ""], ["CHILD(N) 18-23 IN SCHOOL", "IIB;9.\n", "ACTIVE\n", "", "2.5\n", "S EASRTR=$$YN^EASEZT1(EZDATA)\n", "408.22\n", "408.22\n", ".18\n", "Age 18-23 in School?\n", "D H18^EASEZDD\n"], ["APPLICANT GROSS ANNUAL INCOME", "IIC;1.1\n", "ACTIVE\n", "", "1.0\n", "", "408.21\n", "408.21\n", ".14\n", "Gross Annual Inc.\n", ""], ["SPOUSE GROSS ANNUAL INCOME", "IIC;1.2\n", "ACTIVE\n", "", "1.0\n", "", "408.21\n", "408.21\n", ".14\n", "Gross Ann. Inc. (Sp)\n", ""], ["APPLICANT DATE OF BIRTH", "I;7.\n", "ACTIVE\n", "", "1.0\n", "", "2\n", "2\n", ".03\n", "DOB\n", ""], ["CHILD1 EMPLOYMENT INCOME", "IIC;1.3\n", "ACTIVE\n", "", "1.0\n", "", "0\n", "0\n", "0\n", "Employment Inc.(Ch+)\n", ""], ["APPLICANT OTHER INCOME AMOUNTS", "IIC;2.1\n", "ACTIVE\n", "", "2.5\n", "", "408.21\n", "408.21\n", ".08\n", "Other Income\n", "D H08^EASEZDD2\n"], ["SPOUSE OTHER INCOME AMOUNTS", "IIC;2.2\n", "ACTIVE\n", "", "2.5\n", "", "408.21\n", "408.21\n", ".08\n", "Other Income (Sp)\n", "D H08^EASEZDD2\n"], ["CHILD1 OTHER INCOME AMOUNTS", "IIC;2.3\n", "ACTIVE\n", "", "2.5\n", "", "0\n", "0\n", "0\n", "Other Income (Ch+)\n", ""], ["APPLICANT FARM OR BUSINESS", "IIC;3.\n", "ACTIVE\n", "", "1.0\n", "S EASRTR=$$YN^EASEZT1(EZDATA)\n", "0\n", "0\n", "0\n", "Farm/Bus. Income?\n", "S DIR(0)=\"S^Y:YES;N:NO\"\n"], ["APPLICANT TOTAL NON-REIMBURSED MEDICAL EXPENSES", "IID;1.\n", "ACTIVE\n", "", "3.0\n", "", "408.21\n", "408.21\n", "1.12\n", "NonReimb. Med. Exp.\n", "D H112^EASEZDD\n"], ["APPLICANT FUNERAL EXPENSES", "IID;2.\n", "ACTIVE\n", "", "1.0\n", "", "408.21\n", "408.21\n", "1.02\n", "Funeral Expenses\n", "D H102^EASEZDD2\n"], ["APPLICANT EDUCATION EXPENSES", "IID;3.\n", "ACTIVE\n", "", "1.0\n", "", "408.21\n", "408.21\n", "1.03\n", "Education Expenses\n", ""], ["APPLICANT CASH IN BANK", "IIE;1.1\n", "ACTIVE\n", "", "1.0\n", "", "408.21\n", "408.21\n", "2.01\n", "Cash in Bank\n", "D H201^EASEZDD2\n"], ["SPOUSE CASH IN BANK", "IIE;1.2\n", "ACTIVE\n", "", "1.0\n", "", "408.21\n", "408.21\n", "2.01\n", "Cash in Bank (Sp.)\n", "D H201^EASEZDD2\n"], ["RELIGION", "I;8.\n", "ACTIVE\n", "", "1.0\n", "S EASRTR=$$RELIGION^EASEZT2(EZDATA)\n", "2\n", "2\n", ".08\n", "Religion\n", ""], ["APPLICANT LAND/BLDGS. LESS MORTGAGES", "IIE;2.1\n", "ACTIVE\n", "", "1.0\n", "", "408.21\n", "408.21\n", "2.03\n", "Land/Bldgs.\n", "D H203^EASEZDD2\n"], ["SPOUSE LAND/BLDGS. LESS MORTGAGES", "IIE;2.2\n", "ACTIVE\n", "", "1.0\n", "", "408.21\n", "408.21\n", "2.03\n", "Land/Bldgs. (Sp.)\n", "D HD203^EASEZDD2\n"], ["APPLICANT OTHER PROPERTY, ASSETS LESS AMT. OWED", "IIE;3.1\n", "ACTIVE\n", "", "1.0\n", "", "408.21\n", "408.21\n", "2.04\n", "Other Property\n", "D H204^EASEZDD2\n"], ["SPOUSE OTHER PROPERTY, ASSETS LESS AMT. OWED", "IIE;3.2\n", "ACTIVE\n", "", "1.0\n", "", "408.21\n", "408.21\n", "2.04\n", "Other Property (Sp.)\n", "D H204^EASEZDD2\n"], ["DESIGNEE LAST NAME", "I;21A.1\n", "ACTIVE\n", "", "1.0\n", "S EASRTR=$$NAME^EASEZT1(EASAPP,\"DESIGNEE\",EASMULT)\n", "2\n", "2\n", ".341\n", "Designee Name\n", "S DIR(0)=\"FO^1:50^I X'?1.A,X'?1.A1\"\"-\"\"1.A,X'?1.A1\"\" \"\"1.A K X\"\n"], ["DESIGNEE FIRST NAME", "I;21A.2\n", "ACTIVE\n", "", "1.0\n", "", "2\n", "2\n", ".341\n", "", "S DIR(0)=\"FO^1:25^I X'?1.A,X'?1.A1\"\"-\"\"1.A,X'?1.A1\"\" \"\"1.A K X\"\n"], ["DESIGNEE STREET ADDRESS", "I;21A.3\n", "ACTIVE\n", "", "1.0\n", "S EASRTR=$$UC^EASEZT1(EZDATA)\n", "2\n", "2\n", ".343\n", "Designee Street Address\n", ""], ["DESIGNEE CITY", "I;21A.4\n", "ACTIVE\n", "", "1.0\n", "S EASRTR=$$UC^EASEZT1(EZDATA)\n", "2\n", "2\n", ".346\n", "Designee City\n", ""], ["DESIGNEE STATE", "I;21A.5\n", "ACTIVE\n", "", "1.0\n", "S EASRTR=$$STATE^EASEZT1(EZDATA)\n", "2\n", "2\n", ".347\n", "Designee State\n", ""], ["DESIGNEE ZIP", "I;21A.6\n", "ACTIVE\n", "", "1.0\n", "S EASRTR=$$ZIP^EASEZT2(EZDATA)\n", "2\n", "2\n", ".2202\n", "Designee Zipcode\n", "S DIR(0)=\"FO^5:10^S XX=$TR(X,\"\"-\"\",\"\"\"\") I XX'?5N,(XX'?9N) K X\"\n"], ["APPLICANT STREET ADDRESS", "I;9A.\n", "ACTIVE\n", "", "1.0\n", "S EASRTR=$$UC^EASEZT1(EZDATA)\n", "2\n", "2\n", ".111\n", "Street Address\n", ""], ["DESIGNEE RELATIONSHIP", "I;21A.7\n", "ACTIVE\n", "", "1.0\n", "S EASRTR=$$UC^EASEZT1(EZDATA)\n", "2\n", "2\n", ".342\n", "Designee Relationship\n", "S DIR(0)=\"S^1:SELF;2:SPOUSE;3:SON;4:DAUGHTER;5:FATHER;6:MOTHER;99:OTHER\"\n"], ["DESIGNEE HOME PHONE AREA CODE", "I;21B.1\n", "ACTIVE\n", "", "1.0\n", "S EASRTR=$$HOMEPH^EASEZT2(EASAPP,\"DESIGNEE\")\n", "2\n", "2\n", ".349\n", "Designee Home Phone\n", "S DIR(0)=\"FO^3:3^K:X'?3N X\"\n"], ["DESIGNEE HOME PHONE NUMBER", "I;21B.2\n", "ACTIVE\n", "", "1.0\n", "", "2\n", "2\n", ".349\n", "Designee Home Phone\n", "S DIR(0)=\"FO^8:8^K:X'?3N1\"\"-\"\"4N X\"\n"], ["DESIGNEE WORK PHONE AREA CODE", "I;21C.1\n", "ACTIVE\n", "", "1.0\n", "S EASRTR=$$WORKPH^EASEZT2(EASAPP,\"DESIGNEE\")\n", "2\n", "2\n", ".34011\n", "Designee Work Phone\n", "S DIR(0)=\"FO^3:3^K:X'?3N X\"\n"], ["DESIGNEE WORK PHONE NUMBER", "I;21C.2\n", "ACTIVE\n", "", "1.0\n", "", "2\n", "2\n", ".34011\n", "Designee Work Phone\n", "S DIR(0)=\"FO^8:8^K:X'?3N1\"\"-\"\"4N X\"\n"], ["DESIGNEE WORK PHONE EXTENSION", "I;21C.3\n", "ACTIVE\n", "", "1.0\n", "", "2\n", "2\n", ".34011\n", "", "S DIR(0)=\"FO^1:5^K:X'?1.N X\"\n"], ["AMOUNT CONTRIBUTED TO SPOUSE", "IIA;12.1\n", "ACTIVE\n", "", "1.0\n", "", "408.22\n", "408.22\n", ".07\n", "Amt To Sp. Support\n", "D H07^EASEZDD\n"], ["APPLICANT MOTHER MAIDEN NAME", "I;3A.\n", "ACTIVE\n", "", "2.5\n", "S EASRTR=$$LAST^EASEZT1(EZDATA)\n", "2\n", "2\n", ".2403\n", "Mother's Maiden Name\n", "S DIR(0)=\"F^2:35\"\n"], ["APPLICANT SPANISH, HISPANIC, OR LATIN", "I;4A.\n", "ACTIVE\n", "", "2.5\n", "S EASRTR=$$ETHNIC^EASEZT1(EZDATA)\n", "2\n", "2.06\n", ".01\n", "Span/Hisp/Latino?\n", "S DIR(0)=\"S^Y:YES;N:NO;U:UNKNOWN\"\n"], ["APPLICANT RACE - AMERICAN INDIAN OR ALASKA NATIVE", "I;4B.\n", "ACTIVE\n", "", "2.5\n", "S EASRTR=$$RACE^EASEZT1(EZDATA)\n", "2\n", "2.02\n", ".01\n", "Am. Indian/AK Native?\n", "S DIR(0)=\"S^Y:YES;N:NO\"\n"], ["APPLICANT CITY", "I;9B.\n", "ACTIVE\n", "", "1.0\n", "S EASRTR=$$UC^EASEZT1(EZDATA)\n", "2\n", "2\n", ".114\n", "City\n", ""], ["APPLICANT RACE - BLACK OR AFRICAN AMERICAN", "I;4C.\n", "ACTIVE\n", "", "2.5\n", "S EASRTR=$$RACE^EASEZT1(EZDATA)\n", "2\n", "2.02\n", ".01\n", "Black/African Am.?\n", "S DIR(0)=\"S^Y:YES;N:NO\"\n"], ["APPLICANT RACE - NATIVE HAWAIIAN OR OTHER PACIFIC", "I;4D.\n", "ACTIVE\n", "", "2.5\n", "S EASRTR=$$RACE^EASEZT1(EZDATA)\n", "2\n", "2.02\n", ".01\n", "Hawaiian/Pac. Isl.?\n", "S DIR(0)=\"S^Y:YES;N:NO\"\n"], ["APPLICANT RACE - ASIAN", "I;4E.\n", "ACTIVE\n", "", "2.5\n", "S EASRTR=$$RACE^EASEZT1(EZDATA)\n", "2\n", "2.02\n", ".01\n", "Asian?\n", "S DIR(0)=\"S^Y:YES;N:NO\"\n"], ["APPLICANT RACE - WHITE", "I;4F.\n", "ACTIVE\n", "", "2.5\n", "S EASRTR=$$RACE^EASEZT1(EZDATA)\n", "2\n", "2.02\n", ".01\n", "White?\n", "S DIR(0)=\"S^Y:YES;N:NO\"\n"], ["APPLICANT RACE - UNANSWERED", "I;4G.\n", "ACTIVE\n", "", "2.5\n", "S EASRTR=$$RACE^EASEZT1(EZDATA)\n", "2\n", "2.02\n", ".01\n", "Race - Unanswered\n", "S DIR(0)=\"S^Y:YES;N:NO\"\n"], ["APPLICANT PLACE OF BIRTH CITY", "I;8A.\n", "ACTIVE\n", "", "2.5\n", "S EASRTR=$$UC^EASEZT1(EZDATA)\n", "2\n", "2\n", ".092\n", "Place of Birth City\n", ""], ["APPLICANT PLACE OF BIRTH STATE", "I;8B.\n", "ACTIVE\n", "", "2.5\n", "S EASRTR=$$STATE^EASEZT1(EZDATA)\n", "2\n", "2\n", ".093\n", "Place of Birth State\n", ""], ["SEEN AT VA LOCATION", "I;11D.\n", "ACTIVE\n", "", "2.5\n", "S EASRTR=$$UC^EASEZT1(EZDATA)\n", "2\n", "2\n", "1010.152\n", "Seen at VA Location\n", "S DIR(0)=\"P^4:EMZ\"\n"], ["SEEN AT VA MED FACILITY", "I;11C.\n", "ACTIVE\n", "", "2.5\n", "S EASRTR=$$YN^EASEZT1(EZDATA)\n", "2\n", "2\n", "1010.15\n", "Seen at VA Med. Fac\n", "S DIR(0)=\"S^Y:YES;N:NO\"\n"], ["EMAIL", "I;11A.\n", "ACTIVE\n", "", "2.5\n", "", "2\n", "2\n", ".133\n", "Email\n", ""], ["APPLICANT STATE", "I;9C.\n", "ACTIVE\n", "", "1.0\n", "S EASRTR=$$STATE^EASEZT1(EZDATA)\n", "2\n", "2\n", ".115\n", "State\n", ""], ["APPOINTMENT REQUESTED", "I;11B.\n", "ACTIVE\n", "", "2.5\n", "S EASRTR=$$YN^EASEZT1(EZDATA)\n", "2\n", "2\n", "1010.159\n", "Appointment Request\n", ""], ["COMBAT AFTER 11/11/1998", "I;14B2.\n", "ACTIVE\n", "", "2.5\n", "S EASRTR=$$YN^EASEZT1(EZDATA)\n", "2\n", "2\n", "1010.157\n", "Combat Aft. 11/11/98\n", ""], ["NOSE/THROAT RADIUM", "I;14G1.\n", "ACTIVE\n", "", "2.5\n", "S EASRTR=$$YN^EASEZT1(EZDATA)\n", "0\n", "0\n", "0\n", "Nose/Throat Radium\n", ""], ["APPLICANT INSURANCE ADDRESS", "I;17E.\n", "ACTIVE\n", "", "2.5\n", "", "355.33\n", "355.33\n", "21.01\n", "Ins. Address\n", ""], ["APPLICANT INSURANCE CITY", "I;17F.\n", "ACTIVE\n", "", "2.5\n", "", "355.33\n", "355.33\n", "21.04\n", "Ins. City\n", ""], ["APPLICANT INSURANCE STATE", "I;17G.\n", "ACTIVE\n", "", "2.5\n", "S EASRTR=$$STATE^EASEZT1(EZDATA)\n", "355.33\n", "355.33\n", "21.05\n", "Ins. State\n", ""], ["APPLICANT INSURANCE ZIP", "I;17H.\n", "ACTIVE\n", "", "2.5\n", "S EASRTR=$$ZIP^EASEZT2(EZDATA)\n", "355.33\n", "355.33\n", "21.06\n", "Ins. ZIP\n", ""], ["APPLICANT INSURANCE PHONE AREA CODE", "I;17I.\n", "ACTIVE\n", "", "2.5\n", "S EASRTR=$$INSPH^EASEZT2(EASAPP,\"APPLICANT\",EASMULT)\n", "355.33\n", "355.33\n", "20.02\n", "Ins. Phone\n", ""], ["APPLICANT INSURANCE PHONE NUMBER", "I;17J.\n", "ACTIVE\n", "", "2.5\n", "", "355.33\n", "355.33\n", "20.02\n", "Ins. Phone\n", ""], ["OTHER(N) INSURANCE COMPANY", "IA;17A.\n", "ACTIVE\n", "", "2.5\n", "S EASRTR=$$UC^EASEZT1(EZDATA)\n", "355.33\n", "355.33\n", "20.01\n", "Other Health Insurer\n", ""], ["TYPE OF BENEFIT-NURSING HOME", "I;1A.2\n", "ACTIVE\n", "", "1.0\n", "S EASRTR=$$YN^EASEZT1(EZDATA)\n", "0\n", "0\n", "0\n", "Applying for Nursing Home\n", "S DIR(0)=\"S^Y:YES;N:NO\"\n"], ["APPLICANT ZIP", "I;9D.\n", "ACTIVE\n", "", "1.0\n", "S EASRTR=$$ZIP^EASEZT2(EZDATA)\n", "2\n", "2\n", ".1112\n", "Zipcode\n", "S DIR(0)=\"FO^5:10^S XX=$TR(X,\"\"-\"\",\"\"\"\") I XX'?5N,(XX'?9N) K X\"\n"], ["OTHER(N) INSURANCE POLICY HOLDER", "IA;17B.\n", "ACTIVE\n", "", "2.5\n", "S EASRTR=$$UC^EASEZT1(EZDATA)\n", "355.33\n", "355.33\n", "60.07\n", "Policy Holder Name\n", ""], ["OTHER(N) INSURANCE POLICY NUMBER", "IA;17C.\n", "ACTIVE\n", "", "2.5\n", "S EASRTR=$$UC^EASEZT1(EZDATA)\n", "355.33\n", "355.33\n", "60.04\n", "Policy #\n", ""], ["OTHER(N) INSURANCE GROUP CODE", "IA;17D.\n", "ACTIVE\n", "", "2.5\n", "S EASRTR=$$UC^EASEZT1(EZDATA)\n", "355.33\n", "355.33\n", "40.03\n", "Group Code\n", ""], ["OTHER(N) INSURANCE ADDRESS", "IA;17E.\n", "ACTIVE\n", "", "2.5\n", "S EASRTR=$$UC^EASEZT1(EZDATA)\n", "355.33\n", "355.33\n", "21.01\n", "Ins. Address\n", ""], ["OTHER(N) INSURANCE CITY", "IA;17F.\n", "ACTIVE\n", "", "2.5\n", "S EASRTR=$$UC^EASEZT1(EZDATA)\n", "355.33\n", "355.33\n", "21.04\n", "Ins. City\n", ""], ["OTHER(N) INSURANCE STATE", "IA;17G.\n", "ACTIVE\n", "", "2.5\n", "S EASRTR=$$STATE^EASEZT1(EZDATA)\n", "355.33\n", "355.33\n", "21.05\n", "Ins. State\n", ""], ["OTHER(N) INSURANCE ZIP", "IA;17H.\n", "ACTIVE\n", "", "2.5\n", "S EASRTR=$$ZIP^EASEZT2(EZDATA)\n", "355.33\n", "355.33\n", "21.06\n", "Ins. ZIP\n", ""], ["OTHER(N) INSURANCE PHONE AREA CODE", "IA;17I.\n", "ACTIVE\n", "", "2.5\n", "S EASRTR=$$INSPH^EASEZT2(EASAPP,\"OTHER(N)\",EASMULT)\n", "355.33\n", "355.33\n", "20.02\n", "Ins. Phone\n", ""], ["OTHER(N) INSURANCE PHONE NUMBER", "IA;17J.\n", "ACTIVE\n", "", "2.5\n", "", "355.33\n", "355.33\n", "20.02\n", "Ins. Phone\n", ""], ["MILITARY COMP NOT VA COMP", "I;14D3.\n", "ACTIVE\n", "", "2.5\n", "S EASRTR=$$YN^EASEZT1(EZDATA)\n", "2\n", "2\n", ".362\n", "Mil. Comp. Lieu VA\n", "D H362^EASEZDD\n"], ["APPLICANT COUNTY", "I;9E.\n", "ACTIVE\n", "", "1.0\n", "S EASRTR=$$UC^EASEZT1(EZDATA),EASRTR=$$COUNTY^EASEZT1(EASAPP,EASRTR)\n", "2\n", "2\n", ".117\n", "County\n", ""], ["SPOUSE MAIDEN NAME", "IIA;1.5\n", "ACTIVE\n", "", "2.5\n", "S EASRTR=$$LAST^EASEZT1(EZDATA)\n", "408.13\n", "408.13\n", "1.1\n", "Sp. Maiden Name\n", ""], ["APPLICANT FARM OR BUSINESS INCOME", "IIC;3.1\n", "ACTIVE\n", "", "2.5\n", "", "408.21\n", "408.21\n", ".17\n", "Farm/Bus. Income\n", "D H17^EASEZDD2\n"], ["SPOUSE FARM OR BUSINESS INCOME", "IIC;3.2\n", "ACTIVE\n", "", "2.5\n", "", "408.21\n", "408.21\n", ".17\n", "Farm/Bus. Inc. (Sp)\n", "D H17^EASEZDD2\n"], ["CHILD1 FARM OR BUSINESS INCOME", "IIC;3.3\n", "ACTIVE\n", "", "2.5\n", "", "0\n", "0\n", "0\n", "Farm/Bus. Inc. (Ch+)\n", ""], ["CHILD(N) CHILD #", "IIF;7.\n", "ACTIVE\n", "", "2.5\n", "", "0\n", "0\n", "0\n", "Additional Income of\n", ""], ["CHILD(N) EMPLOYMENT INCOME", "IIF;7.1\n", "ACTIVE\n", "", "2.5\n", "", "408.21\n", "408.21\n", ".14\n", "Employment Income\n", "D H14^EASEZDD2\n"], ["CHILD(N) FARM/BUS INCOME", "IIF;7.2\n", "ACTIVE\n", "", "2.5\n", "", "408.21\n", "408.21\n", ".17\n", "Farm/Bus. Inc.\n", "D H17^EASEZDD2\n"], ["CHILD(N) OTHER INCOME AMOUNTS", "IIF;7.3\n", "ACTIVE\n", "", "2.5\n", "", "408.21\n", "408.21\n", ".08\n", "Other Income\n", "D H08^EASEZDD2\n"], ["ASSET(N) CHILD #", "IIG;9.\n", "ACTIVE\n", "", "2.5\n", "", "0\n", "0\n", "0\n", "Additional Assets of\n", ""], ["ASSET(N) CASH IN BANK", "IIG;9.1\n", "ACTIVE\n", "", "2.5\n", "", "408.21\n", "408.21\n", "2.01\n", "Cash in Bank\n", "D H201^EASEZDD2\n"], ["APPLICANT HOME PHONE AREA CODE", "I;10.1\n", "ACTIVE\n", "", "1.0\n", "S EASRTR=$$HOMEPH^EASEZT2(EASAPP,\"APPLICANT\")\n", "2\n", "2\n", ".131\n", "Home Phone\n", "S DIR(0)=\"FO^3:3^K:X'?3N X\"\n"], ["ASSET(N) LAND/BLDGS. LESS MORTGAGES", "IIG;9.2\n", "ACTIVE\n", "", "2.5\n", "", "408.21\n", "408.21\n", "2.03\n", "Land/Bldgs.\n", "D HD203^EASEZDD2\n"], ["ASSET(N) OTHER PROPERTY, ASSETS LESS AMT. OWED", "IIG;9.3\n", "ACTIVE\n", "", "2.5\n", "", "408.21\n", "408.21\n", "2.04\n", "Other Property\n", "D H204^EASEZDD2\n"], ["CHILD1 CASH IN BANK", "IIE;1.3\n", "ACTIVE\n", "", "2.5\n", "", "0\n", "0\n", "0\n", "Cash in Bank (Ch+)\n", ""], ["CHILD1 LAND/BLDGS. LESS MORTGAGES", "IIE;2.3\n", "ACTIVE\n", "", "2.5\n", "", "0\n", "0\n", "0\n", "Land/Bldgs. (Ch+)\n", ""], ["CHILD1 OTHER PROPERTY, ASSETS LESS AMT. OWED", "IIE;3.3\n", "ACTIVE\n", "", "2.5\n", "", "0\n", "0\n", "0\n", "Other Property (Ch+)\n", ""], ["APPLICANT CASH IN BANK2", "IIE;1.\n", "ACTIVE\n", "", "2.5\n", "", "0\n", "0\n", "0\n", "Cash in Bank\n", ""], ["APPLICANT REAL PROPERTY LESS MORTGAGES2", "IIE;2.\n", "ACTIVE\n", "", "2.5\n", "", "0\n", "0\n", "0\n", "Real Property\n", ""], ["APPLICANT STOCKS BONDS ASSETS LESS DEBTS2", "IIE;3.\n", "ACTIVE\n", "", "2.5\n", "", "0\n", "0\n", "0\n", "Other Property\n", ""], ["APPLICANT HOME PHONE NUMBER", "I;10.2\n", "ACTIVE\n", "", "1.0\n", "", "2\n", "2\n", ".131\n", "Home Phone\n", "S DIR(0)=\"FO^8:8^K:X'?3N1\"\"-\"\"4N X\"\n"], ["APPLICANT EMPLOYMENT INCOME", "IIC;1.4\n", "ACTIVE\n", "", "2.5\n", "", "408.21\n", "408.21\n", ".14\n", "Employment Income\n", "D H14^EASEZDD2\n"], ["SPOUSE EMPLOYMENT INCOME", "IIC;1.5\n", "ACTIVE\n", "", "2.5\n", "", "408.21\n", "408.21\n", ".14\n", "Employment Inc. (Sp)\n", "D H14^EASEZDD2\n"], ["CHILD1 GROSS ANNUAL INCOME2", "IIC;1.6\n", "ACTIVE\n", "", "2.5\n", "", "0\n", "0\n", "0\n", "Employment Inc.(Ch+)\n", ""], ["DISABILITY DISCHARGE CLAIMED", "I;14D4.\n", "ACTIVE\n", "", "2.5\n", "S EASRTR=$$YN^EASEZT1(EZDATA)\n", "2\n", "2\n", ".3603\n", "Disab. Discharge?\n", ""], ["APPLICANT CELLULAR PHONE AREA CODE", "I;11A1.\n", "ACTIVE\n", "", "3.0\n", "S EASRTR=$$CELLPH^EASEZT2(EASAPP,\"APPLICANT\")\n", "2\n", "2\n", ".134\n", "Cell Phone\n", "D AC^EASEZDD\n"], ["APPLICANT CELLULAR PHONE NUMBER", "I;11A2.\n", "ACTIVE\n", "", "3.0\n", "", "2\n", "2\n", ".134\n", "Cell Phone\n", "D PN^EASEZDD\n"], ["APPLICANT PAGER PHONE AREA CODE", "I;11A3.\n", "ACTIVE\n", "", "3.0\n", "S EASRTR=$$PAGERPH^EASEZT2(EASAPP,\"APPLICANT\")\n", "2\n", "2\n", ".135\n", "Pager #\n", "D AC^EASEZDD\n"], ["APPLICANT PAGER PHONE NUMBER", "I;11A4.\n", "ACTIVE\n", "", "3.0\n", "", "2\n", "2\n", ".135\n", "Pager #\n", "D PN^EASEZDD\n"], ["APPLICANT PROVINCE", "I;9F.\n", "ACTIVE\n", "", "3.0\n", "", "2\n", "2\n", ".1171\n", "Province\n", ""], ["APPLICANT WORK PHONE AREA CODE", "I;11.1\n", "ACTIVE\n", "", "1.0\n", "S EASRTR=$$WORKPH^EASEZT2(EASAPP,\"APPLICANT\")\n", "2\n", "2\n", ".132\n", "Work Phone\n", "S DIR(0)=\"FO^3:3^K:X'?3N X\"\n"], ["APPLICANT POSTAL CODE", "I;9G.\n", "ACTIVE\n", "", "3.0\n", "", "2\n", "2\n", ".1172\n", "Postal Code\n", ""], ["APPLICANT COUNTRY", "I;9H.\n", "ACTIVE\n", "", "3.0\n", "S EASRTR=$$COUNTRY^EASEZT1(EZDATA)\n", "2\n", "2\n", ".1173\n", "Country\n", ""], ["APPLICANT WORK PHONE NUMBER", "I;11.2\n", "ACTIVE\n", "", "1.0\n", "", "2\n", "2\n", ".132\n", "Work Phone\n", "S DIR(0)=\"FO^8:8^K:X'?3N1\"\"-\"\"4N X\"\n"], ["APPLICANT WORK PHONE EXTENSION", "I;11.3\n", "ACTIVE\n", "", "1.0\n", "", "2\n", "2\n", ".132\n", "", "S DIR(0)=\"FO^1:5^K:X'?1.N X\"\n"], ["MARITAL STATUS", "I;12.\n", "ACTIVE\n", "", "1.0\n", "S EASRTR=$$MARR^EASEZT2(EZDATA)\n", "2\n", "2\n", ".05\n", "Marital Status\n", ""], ["LAST BRANCH OF SERVICE", "I;13A.\n", "ACTIVE\n", "", "1.0\n", "S EASRTR=$$SVCBRCH^EASEZT2(EZDATA)\n", "2\n", "2.3216\n", ".03\n", "Last Br. of Service\n", ""], ["LAST ENTRY DATE", "I;13B.\n", "ACTIVE\n", "", "1.0\n", "S EASRTR=$$XDATE^EASEZT1(EZDATA)\n", "2\n", "2.3216\n", ".01\n", "Last Entry Date\n", ""], ["TYPE OF BENEFIT-DOMICILIARY", "I;1A.3\n", "ACTIVE\n", "", "1.0\n", "S EASRTR=$$YN^EASEZT1(EZDATA)\n", "0\n", "0\n", "0\n", "Applying for Domiciliary\n", "S DIR(0)=\"S^Y:YES;N:NO\"\n"], ["LAST DISCHARGE DATE", "I;13C.\n", "ACTIVE\n", "", "1.0\n", "S EASRTR=$$XDATE^EASEZT1(EZDATA)\n", "2\n", "2.3216\n", ".02\n", "Last Discharge Date\n", ""], ["LAST DISCHARGE TYPE", "I;13D.\n", "ACTIVE\n", "", "1.0\n", "", "2\n", "2.3216\n", ".06\n", "Discharge Type\n", ""], ["SERVICE NUMBER", "I;13E.\n", "ACTIVE\n", "", "1.0\n", "", "2\n", "2.3216\n", ".05\n", "Service Number\n", ""], ["PURPLE HEART", "I;14A1.\n", "ACTIVE\n", "", "1.0\n", "S EASRTR=$$YN^EASEZT1(EZDATA)\n", "2\n", "2\n", ".531\n", "Purple Heart?\n", ""], ["PRISONER OF WAR", "I;14A2.\n", "ACTIVE\n", "", "1.0\n", "S EASRTR=$$YN^EASEZT1(EZDATA)\n", "2\n", "2\n", ".525\n", "POW?\n", ""], ["SERVICE-CONNECTED", "I;14B.\n", "ACTIVE\n", "", "1.0\n", "S EASRTR=$$YN^EASEZT1(EZDATA)\n", "2\n", "2\n", ".301\n", "Service-Connected?\n", ""], ["RATED PERCENTAGE", "I;14B1.\n", "ACTIVE\n", "", "1.0\n", "", "2\n", "2\n", ".302\n", "SC %\n", ""], ["VA PENSION", "I;14C.\n", "ACTIVE\n", "", "1.0\n", "S EASRTR=$$YN^EASEZT1(EZDATA)\n", "2\n", "2\n", ".36235\n", "VA Pension?\n", ""], ["RETIRED FROM MILITARY", "I;14D.\n", "ACTIVE\n", "", "1.0\n", "S EASRTR=$$YN^EASEZT1(EZDATA)\n", "2\n", "2\n", ".36255\n", "Ret. From Military?\n", ""], ["DISABILITY RETIREMENT FROM MILITARY", "I;14D1.\n", "ACTIVE\n", "", "1.0\n", "S EASRTR=$$YN^EASEZT1(EZDATA)\n", "2\n", "2\n", ".3602\n", "Mil. Disab. Ret.?\n", ""], ["TYPE OF BENEFIT-DENTAL", "I;1A.4\n", "ACTIVE\n", "", "1.0\n", "S EASRTR=$$YN^EASEZT1(EZDATA)\n", "0\n", "0\n", "0\n", "Applying for Dental\n", "S DIR(0)=\"S^Y:YES;N:NO\"\n"], ["REGULAR RETIREMENT FROM MILITARY", "I;14D2.\n", "ACTIVE\n", "", "1.0\n", "S EASRTR=$$YN^EASEZT1(EZDATA)\n", "2\n", "2\n", ".36255\n", "Mil. Regular Ret.?\n", ""], ["TOXINS IN GULF WAR", "I;14E.\n", "ACTIVE\n", "", "1.0\n", "S EASRTR=$$YN^EASEZT1(EZDATA)\n", "2\n", "2\n", ".322013\n", "Gulf War Toxin Exp.?\n", ""], ["AGENT ORANGE", "I;14F.\n", "ACTIVE\n", "", "1.0\n", "S EASRTR=$$YN^EASEZT1(EZDATA)\n", "2\n", "2\n", ".32102\n", "Agent Orange Exp.?\n", ""], ["RADIATION EXPOSURE", "I;14G.\n", "ACTIVE\n", "", "1.0\n", "S EASRTR=$$YN^EASEZT1(EZDATA)\n", "2\n", "2\n", ".32103\n", "Radiation Exp.?\n", ""], ["DENTAL INJURY", "I;14H.\n", "ACTIVE\n", "", "1.0\n", "S EASRTR=$$YN^EASEZT1(EZDATA)\n", "2\n", "2\n", ".368\n", "Mil. Dental Injury?\n", ""], ["SPINAL CORD INJURY", "I;14I.\n", "ACTIVE\n", "", "1.0\n", "S EASRTR=$$YN^EASEZT1(EZDATA)\n", "0\n", "0\n", "0\n", "Spinal Cord Injury?\n", ""], ["ELIGIBLE FOR MEDICAID", "I;14J.\n", "ACTIVE\n", "", "1.0\n", "S EASRTR=$$YN^EASEZT1(EZDATA)\n", "2\n", "2\n", ".381\n", "Elig. For Medicaid?\n", ""], ["MEDICARE PART A", "I;14K.\n", "ACTIVE\n", "", "1.0\n", "S EASRTR=$$YN^EASEZT1(EZDATA)\n", "355.33\n", "355.33\n", "20.01\n", "Medicare Part A?\n", "S DIR(0)=\"S^Y:YES;N:NO\"\n"], ["MEDICARE PART A EFFECTIVE DATE", "I;14K1.\n", "ACTIVE\n", "", "1.0\n", "S EASRTR=$$XDATE^EASEZT1(EZDATA)\n", "355.33\n", "355.33\n", "60.02\n", "Part A Effective DT\n", ""], ["MEDICARE PART B", "I;14L.\n", "ACTIVE\n", "", "1.0\n", "S EASRTR=$$YN^EASEZT1(EZDATA)\n", "355.33\n", "355.33\n", "20.01\n", "Medicare Part B?\n", "S DIR(0)=\"S^Y:YES;N:NO\"\n"], ["TYPE OF BENEFIT-ENROLLMENT", "I;1A.5\n", "ACTIVE\n", "", "1.0\n", "S EASRTR=$$YN^EASEZT1(EZDATA)\n", "0\n", "0\n", "0\n", "Applying for Enrollment\n", "S DIR(0)=\"S^Y:YES;N:NO\"\n"], ["MEDICARE PART B EFFECTIVE DATE", "I;14L1.\n", "ACTIVE\n", "", "1.0\n", "S EASRTR=$$XDATE^EASEZT1(EZDATA)\n", "355.33\n", "355.33\n", "60.02\n", "Part B Effective DT\n", ""], ["MEDICARE CLAIM NUMBER", "I;14M.\n", "ACTIVE\n", "", "1.0\n", "", "0\n", "0\n", "0\n", "Medicare Claim #\n", ""], ["SIGNEE ON MEDICARE CARD", "I;14N.\n", "ACTIVE\n", "", "1.0\n", "S EASRTR=$$UC^EASEZT1(EZDATA)\n", "355.33\n", "355.33\n", "60.07\n", "Medicare Card Name\n", ""], ["APPLICANT EMPLOYMENT STATUS", "I;15A.1\n", "ACTIVE\n", "", "1.0\n", "S EASRTR=$$EMPLOY^EASEZT2(EZDATA)\n", "2\n", "2\n", ".31115\n", "Emp. Status\n", ""], ["APPLICANT DATE OF RETIREMENT", "I;15A.2\n", "ACTIVE\n", "", "2.5\n", "S EASRTR=$$XDATE^EASEZT1(EZDATA)\n", "2\n", "2\n", ".31116\n", "Retirement Date\n", "S DIR(0)=\"D^::AEP\"\n"], ["APPLICANT EMPLOYER", "I;15B.1\n", "ACTIVE\n", "", "1.0\n", "S EASRTR=$$UC^EASEZT1(EZDATA)\n", "2\n", "2\n", ".3111\n", "Employer\n", ""], ["APPLICANT EMPLOYER STREET ADDRESS", "I;15B.2\n", "ACTIVE\n", "", "1.0\n", "S EASRTR=$$UC^EASEZT1(EZDATA)\n", "2\n", "2\n", ".3113\n", "Emp. Street Addr.\n", ""], ["APPLICANT EMPLOYER CITY", "I;15B.3\n", "ACTIVE\n", "", "1.0\n", "S EASRTR=$$UC^EASEZT1(EZDATA)\n", "2\n", "2\n", ".3116\n", "Emp. City\n", ""], ["APPLICANT EMPLOYER STATE", "I;15B.4\n", "ACTIVE\n", "", "1.0\n", "S EASRTR=$$STATE^EASEZT1(EZDATA)\n", "2\n", "2\n", ".3117\n", "Emp. State\n", ""], ["APPLICANT EMPLOYER ZIP", "I;15B.5\n", "ACTIVE\n", "", "1.0\n", "S EASRTR=$$ZIP^EASEZT2(EZDATA)\n", "2\n", "2\n", ".2205\n", "Emp. Zip\n", "S DIR(0)=\"FO^5:10^S XX=$TR(X,\"\"-\"\",\"\"\"\") I XX'?5N,(XX'?9N) K X\"\n"], ["FACILITY TO RECEIVE 1010EZ", "I;1B.\n", "ACTIVE\n", "", "1.0\n", "S EASRTR=$$UC^EASEZT1(EZDATA)\n", "0\n", "0\n", "0\n", "Facility Applying To\n", ""], ["APPLICANT EMPLOYER PHONE AREA CODE", "I;15B.6\n", "ACTIVE\n", "", "1.0\n", "S EASRTR=$$EMPLPH^EASEZT2(EASAPP,\"APPLICANT\")\n", "2\n", "2\n", ".3119\n", "Emp. Phone Number\n", "S DIR(0)=\"FO^3:3^K:X'?3N X\"\n"], ["APPLICANT EMPLOYER PHONE NUMBER", "I;15B.7\n", "ACTIVE\n", "", "1.0\n", "", "2\n", "2\n", ".3119\n", "Emp. Phone\n", "S DIR(0)=\"FO^8:8^K:X'?3N1\"\"-\"\"4N X\"\n"], ["APPLICANT EMPLOYER PHONE EXTENSION", "I;15B.8\n", "ACTIVE\n", "", "1.0\n", "", "2\n", "2\n", ".3119\n", "Emp. Phone Ext.\n", "S DIR(0)=\"FO^1:5^K:X'?1.N X\"\n"], ["SPOUSE EMPLOYMENT STATUS", "I;16A.1\n", "ACTIVE\n", "", "1.0\n", "S EASRTR=$$EMPLOY^EASEZT2(EZDATA)\n", "2\n", "2\n", ".2515\n", "Sp. Empl. Status\n", ""], ["SPOUSE DATE OF RETIREMENT", "I;16A.2\n", "ACTIVE\n", "", "2.5\n", "S EASRTR=$$XDATE^EASEZT1(EZDATA)\n", "2\n", "2\n", ".2516\n", "Sp. Retirement Date\n", "S DIR(0)=\"D^::AEP\"\n"], ["SPOUSE EMPLOYER", "I;16B.1\n", "ACTIVE\n", "", "1.0\n", "S EASRTR=$$UC^EASEZT1(EZDATA)\n", "2\n", "2\n", ".251\n", "Sp. Employer\n", ""], ["SPOUSE EMPLOYER STREET ADDRESS", "I;16B.2\n", "ACTIVE\n", "", "1.0\n", "S EASRTR=$$UC^EASEZT1(EZDATA)\n", "2\n", "2\n", ".252\n", "Sp. Empl. Street Addr.\n", ""], ["SPOUSE EMPLOYER CITY", "I;16B.3\n", "ACTIVE\n", "", "1.0\n", "S EASRTR=$$UC^EASEZT1(EZDATA)\n", "2\n", "2\n", ".255\n", "Sp. Employer City\n", ""], ["SPOUSE EMPLOYER STATE", "I;16B.4\n", "ACTIVE\n", "", "1.0\n", "S EASRTR=$$STATE^EASEZT1(EZDATA)\n", "2\n", "2\n", ".256\n", "Sp. Employer State\n", ""], ["SPOUSE EMPLOYER ZIP", "I;16B.5\n", "ACTIVE\n", "", "1.0\n", "S EASRTR=$$ZIP^EASEZT2(EZDATA)\n", "2\n", "2\n", ".2206\n", "Sp. Employer Zip\n", "S DIR(0)=\"FO^5:10^S XX=$TR(X,\"\"-\"\",\"\"\"\") I XX'?5N,(XX'?9N) K X\"\n"], ["APPLICANT LAST NAME", "I;2.1\n", "ACTIVE\n", "", "1.0\n", "S EASRTR=$$NAME^EASEZT1(EASAPP,\"APPLICANT\",EASMULT)\n", "2\n", "2\n", ".01\n", "Applicant Name\n", "S DIR(0)=\"FO^1:50^I X'?1.A,X'?1.A1\"\"-\"\"1.A,X'?1.A1\"\" \"\"1.A K X\"\n"], ["SPOUSE EMPLOYER PHONE AREA CODE", "I;16B.6\n", "ACTIVE\n", "", "1.0\n", "S EASRTR=$$EMPLPH^EASEZT2(EASAPP,\"SPOUSE\")\n", "2\n", "2\n", ".258\n", "Sp. Employer Phone Number\n", "S DIR(0)=\"FO^3:3^K:X'?3N X\"\n"], ["SPOUSE EMPLOYER PHONE NUMBER", "I;16B.7\n", "ACTIVE\n", "", "1.0\n", "", "2\n", "2\n", ".258\n", "Sp. Employer Phone\n", "S DIR(0)=\"FO^8:8^K:X'?3N1\"\"-\"\"4N X\"\n"], ["SPOUSE EMPLOYER PHONE EXTENSION", "I;16B.8\n", "ACTIVE\n", "", "1.0\n", "", "2\n", "2\n", ".258\n", "Sp. Employer Phone Ext.\n", "S DIR(0)=\"FO^1:5^K:X'?1.N X\"\n"], ["APPLICANT HAS INSURANCE", "I;17.\n", "ACTIVE\n", "", "1.0\n", "S EASRTR=$$YN^EASEZT1(EZDATA)\n", "0\n", "0\n", "0\n", "Health Insurance?\n", "S DIR(0)=\"S^Y:YES;N:NO\"\n"], ["APPLICANT INSURANCE COMPANY", "I;17A.\n", "ACTIVE\n", "", "1.0\n", "S EASRTR=$$UC^EASEZT1(EZDATA)\n", "355.33\n", "355.33\n", "20.01\n", "Health Insurer\n", ""], ["APPLICANT INSURANCE POLICY HOLDER", "I;17B.\n", "ACTIVE\n", "", "1.0\n", "S EASRTR=$$UC^EASEZT1(EZDATA)\n", "355.33\n", "355.33\n", "60.07\n", "Policy Holder Name\n", ""], ["APPLICANT INSURANCE POLICY NUMBER", "I;17C.\n", "ACTIVE\n", "", "1.0\n", "S EASRTR=$$UC^EASEZT1(EZDATA)\n", "355.33\n", "355.33\n", "60.04\n", "Policy #\n", ""], ["APPLICANT INSURANCE GROUP CODE", "I;17D.\n", "ACTIVE\n", "", "1.0\n", "S EASRTR=$$UC^EASEZT1(EZDATA)\n", "355.33\n", "355.33\n", "40.03\n", "Group Code\n", ""], ["SPOUSE HAS INSURANCE", "I;18.\n", "ACTIVE\n", "", "1.0\n", "S EASRTR=$$YN^EASEZT1(EZDATA)\n", "0\n", "0\n", "0\n", "Sp. Health Ins.?\n", "S DIR(0)=\"S^Y:YES;N:NO\"\n"], ["SPOUSE INSURANCE COMPANY", "I;18A.\n", "ACTIVE\n", "", "1.0\n", "S EASRTR=$$UC^EASEZT1(EZDATA)\n", "355.33\n", "355.33\n", "20.01\n", "Sp. Insurance Co.\n", ""], ["APPLICANT FIRST NAME", "I;2.2\n", "ACTIVE\n", "", "1.0\n", "", "2\n", "2\n", ".01\n", "", "S DIR(0)=\"FO^1:25^I X'?1.A,X'?1.A1\"\"-\"\"1.A,X'?1.A1\"\" \"\"1.A K X\"\n"], ["SPOUSE INSURANCE POLICY HOLDER", "I;18B.\n", "ACTIVE\n", "", "1.0\n", "S EASRTR=$$UC^EASEZT1(EZDATA)\n", "355.33\n", "355.33\n", "60.07\n", "Sp. Pol. Holder Name\n", ""], ["SPOUSE INSURANCE POLICY NUMBER", "I;18C.\n", "ACTIVE\n", "", "1.0\n", "S EASRTR=$$UC^EASEZT1(EZDATA)\n", "355.33\n", "355.33\n", "60.04\n", "Sp. Policy #\n", ""], ["SPOUSE INSURANCE GROUP CODE", "I;18D.\n", "ACTIVE\n", "", "1.0\n", "S EASRTR=$$UC^EASEZT1(EZDATA)\n", "355.33\n", "355.33\n", "40.03\n", "Sp. Group Code\n", ""], ["NEXT-OF-KIN LAST NAME", "I;19A.1\n", "ACTIVE\n", "", "1.0\n", "S EASRTR=$$NAME^EASEZT1(EASAPP,\"NEXT-OF-KIN\",EASMULT)\n", "2\n", "2\n", ".211\n", "NOK Name\n", "S DIR(0)=\"FO^1:50^I X'?1.A,X'?1.A1\"\"-\"\"1.A,X'?1.A1\"\" \"\"1.A K X\"\n"], ["NEXT-OF-KIN FIRST NAME", "I;19A.2\n", "ACTIVE\n", "", "1.0\n", "", "2\n", "2\n", ".211\n", "", "S DIR(0)=\"FO^1:25^I X'?1.A,X'?1.A1\"\"-\"\"1.A,X'?1.A1\"\" \"\"1.A K X\"\n"], ["NEXT-OF-KIN STREET ADDRESS", "I;19A.3\n", "ACTIVE\n", "", "1.0\n", "S EASRTR=$$UC^EASEZT1(EZDATA)\n", "2\n", "2\n", ".213\n", "NOK Street Address\n", ""], ["NEXT-OF-KIN CITY", "I;19A.4\n", "ACTIVE\n", "", "1.0\n", "S EASRTR=$$UC^EASEZT1(EZDATA)\n", "2\n", "2\n", ".216\n", "NOK City\n", ""], ["NEXT-OF-KIN STATE", "I;19A.5\n", "ACTIVE\n", "", "1.0\n", "S EASRTR=$$STATE^EASEZT1(EZDATA)\n", "2\n", "2\n", ".217\n", "NOK State\n", ""], ["NEXT-OF-KIN ZIP", "I;19A.6\n", "ACTIVE\n", "", "1.0\n", "S EASRTR=$$ZIP^EASEZT2(EZDATA)\n", "2\n", "2\n", ".2207\n", "NOK Zipcode\n", "S DIR(0)=\"FO^5:10^S XX=$TR(X,\"\"-\"\",\"\"\"\") I XX'?5N,(XX'?9N) K X\"\n"], ["NEXT-OF-KIN RELATIONSHIP", "I;19A.7\n", "ACTIVE\n", "", "1.0\n", "S EASRTR=$$UC^EASEZT1(EZDATA)\n", "2\n", "2\n", ".212\n", "NOK Relationship\n", "S DIR(0)=\"S^1:SELF;2:SPOUSE;3:SON;4:DAUGHTER;5:FATHER;6:MOTHER;99:OTHER\"\n"], ["APPLICANT MIDDLE NAME", "I;2.3\n", "ACTIVE\n", "", "1.0\n", "", "2\n", "2\n", ".01\n", "", "S DIR(0)=\"FO^1:25^I X'?1.A,X'?1.A1\"\"-\"\"1.A,X'?1.A1\"\" \"\"1.A K X\"\n"], ["NEXT-OF-KIN HOME PHONE AREA CODE", "I;19B.1\n", "ACTIVE\n", "", "1.0\n", "S EASRTR=$$HOMEPH^EASEZT2(EASAPP,\"NEXT-OF-KIN\")\n", "2\n", "2\n", ".219\n", "NOK Home Phone\n", "S DIR(0)=\"FO^3:3^K:X'?3N X\"\n"], ["NEXT-OF-KIN HOME PHONE NUMBER", "I;19B.2\n", "ACTIVE\n", "", "1.0\n", "", "2\n", "2\n", ".219\n", "NOK Home Phone\n", "S DIR(0)=\"FO^8:8^K:X'?3N1\"\"-\"\"4N X\"\n"], ["NEXT-OF-KIN WORK PHONE AREA CODE", "I;19C.1\n", "ACTIVE\n", "", "1.0\n", "S EASRTR=$$WORKPH^EASEZT2(EASAPP,\"NEXT-OF-KIN\")\n", "2\n", "2\n", ".21011\n", "NOK Work Phone\n", "S DIR(0)=\"FO^3:3^K:X'?3N X\"\n"], ["NEXT-OF-KIN WORK PHONE NUMBER", "I;19C.2\n", "ACTIVE\n", "", "1.0\n", "", "2\n", "2\n", ".21011\n", "NOK Work Phone\n", "S DIR(0)=\"FO^8:8^K:X'?3N1\"\"-\"\"4N X\"\n"], ["NEXT-OF-KIN WORK PHONE EXTENSION", "I;19C.3\n", "ACTIVE\n", "", "1.0\n", "", "2\n", "2\n", ".21011\n", "", "S DIR(0)=\"FO^1:5^K:X'?1.N X\"\n"], ["E-CONTACT LAST NAME", "I;20A.1\n", "ACTIVE\n", "", "1.0\n", "S EASRTR=$$NAME^EASEZT1(EASAPP,\"E-CONTACT\",EASMULT)\n", "2\n", "2\n", ".331\n", "E-Cont. Name\n", "S DIR(0)=\"FO^1:50^I X'?1.A,X'?1.A1\"\"-\"\"1.A,X'?1.A1\"\" \"\"1.A K X\"\n"], ["E-CONTACT FIRST NAME", "I;20A.2\n", "ACTIVE\n", "", "1.0\n", "", "2\n", "2\n", ".331\n", "E-Cont. First Name\n", "S DIR(0)=\"FO^1:25^I X'?1.A,X'?1.A1\"\"-\"\"1.A,X'?1.A1\"\" \"\"1.A K X\"\n"], ["E-CONTACT STREET ADDRESS", "I;20A.3\n", "ACTIVE\n", "", "1.0\n", "S EASRTR=$$UC^EASEZT1(EZDATA)\n", "2\n", "2\n", ".333\n", "E-Cont. Street Addr.\n", ""], ["E-CONTACT CITY", "I;20A.4\n", "ACTIVE\n", "", "1.0\n", "S EASRTR=$$UC^EASEZT1(EZDATA)\n", "2\n", "2\n", ".336\n", "E-Cont. City\n", ""], ["E-CONTACT STATE", "I;20A.5\n", "ACTIVE\n", "", "1.0\n", "S EASRTR=$$STATE^EASEZT1(EZDATA)\n", "2\n", "2\n", ".337\n", "E-Cont. State\n", ""]]}