145 lines
8.5 KiB
Mathematica
145 lines
8.5 KiB
Mathematica
EASEZRP2 ;ALB/AMA - Print 1010EZR, Cont., Page 2
|
|
;;1.0;ENROLLMENT APPLICATION SYSTEM;**57**;Mar 15, 2001
|
|
;
|
|
Q
|
|
;
|
|
EN(EALNE,EAINFO,EASDG) ; Entry point, 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 EASD
|
|
;
|
|
D HDR^EASEZRPF(.EALNE,.EAINFO)
|
|
S EASD=$NA(^TMP("EASEZR",$J,2))
|
|
D PAP
|
|
D FD
|
|
D DEP
|
|
D INC
|
|
D EXP
|
|
;
|
|
D FT^EASEZRPF(.EALNE,.EAINFO)
|
|
Q
|
|
;
|
|
PAP ; Print SECTION IV - PAPERWORK REDUCTION ACT AND PRIVACY ACT INFORMATION
|
|
;
|
|
W !?34,"SECTION IV - PAPERWORK REDUCTION ACT AND PRIVACY ACT INFORMATION"
|
|
W ?131,$C(13) W:EALNE("ULC")="-" ! W EALNE("UL")
|
|
;
|
|
W !?5,"The Paperwork Reduction Act of 1995 requires us to notify you that this information collection is in accordance with the"
|
|
W !,"clearance requirements of Section 3507 of the Paperwork Reduction Act of 1995. We may not conduct or sponsor, and you are not"
|
|
W !,"required to respond to, a collection of information unless it displays a valid OMB number. We anticipate that the time expended by"
|
|
W !,"all individuals who must complete this form will average 24 minutes. This includes the time it will take to read instructions,"
|
|
W !,"gather the necessary facts and fill out the form."
|
|
W !?5,"Privacy Act Information: VA is asking you to provide the information on this form under 38 U.S.C. Sections 1710, 1712, and"
|
|
W !,"1722 in order for VA to determine your eligibility for medical benefits. Information you supply may be verified through a"
|
|
W !,"computer-matching program. VA may disclose the information that you put on the form as permitted by law. VA may make a ""routine"
|
|
W !,"use"" disclosure of the information as outlined in the Privacy Act systems of records notices and in accordance with the VHA Notice"
|
|
W !,"of Privacy Practices. You do not have to provide the information to VA, but if you don't, VA may be unable to process your request"
|
|
W !,"and serve your medical needs. Failure to furnish the information will not have any affect on any other benefits to which you may"
|
|
W !,"be entitled. If you provide VA your Social Security Number, VA will use it to administer your VA benefits. VA may also use this"
|
|
W !,"information to identify veterans and persons claiming or receiving VA benefits and their records, and for other purposes"
|
|
W !,"authorized or required by law."
|
|
W ?131,$C(13) W:EALNE("ULC")="-" ! W EALNE("UL")
|
|
Q
|
|
;
|
|
FD ; Print VA 10-10EZR SECTION V - FINANCIAL DISCLOSURE
|
|
;
|
|
W !?49,"SECTION V - FINANCIAL DISCLOSURE"
|
|
W ?131,$C(13) W:EALNE("ULC")="-" ! W EALNE("UL")
|
|
;
|
|
W !?5,"Failure to disclose your previous year's financial information may affect your eligibility for health care benefits. Your"
|
|
W !,"financial information is used by VA to accurately determine if you should be responsible for copayments for office visits, pharmacy,"
|
|
W !,"inpatient, nursing home and long term care, and for some veterans, priority for enrollment. You are not required to provide this"
|
|
W !,"information. However, completing the financial dislosure section results in a more accurate determination of your eligibility for"
|
|
W !,"health care services/benefits."
|
|
;
|
|
N EZRY,EZRN S (EZRY,EZRN)="___"
|
|
; IF NO ENTRY, THEN NO MEANS TEST, SO NO ANSWER
|
|
; IF @EASD@(998)="Y", THEN VET DECLINES TO GIVE INFO, SO ANSWER "NO"
|
|
I $D(@EASD@(998)) D
|
|
. S:@EASD@(998)="YES" EZRN=" X "
|
|
. S:@EASD@(998)="NO" EZRY=" X "
|
|
;
|
|
W !?3,EZRN," NO, I DO NOT WISH TO PROVIDE INFORMATION IN SECTIONS VI THROUGH IX. I understand that VA is currently not enrolling"
|
|
W !,"veterans who decline to provide financial information unless other special eligibility factors exist. However, if I am already"
|
|
W !,"enrolled, I agree to pay the applicable VA copayments. (Sign and date the application in Section XI.)"
|
|
;
|
|
W !?3,EZRY," YES, I WILL PROVIDE SPECIFIC INCOME AND/OR ASSET INFORMATION TO ESTABLISH MY ELIGIBILITY FOR CARE. (Complete all sections"
|
|
W !,"below that apply to you with last calendar year's information. Sign and date the application in Section XI.)"
|
|
W ?131,$C(13) W:EALNE("ULC")="-" ! W EALNE("UL")
|
|
Q
|
|
;
|
|
DEP ; Print out VA 10-10EZR Section VI, Dependent Information
|
|
;
|
|
W !?24,"SECTION VI - DEPENDENT INFORMATION (Use a separate sheet for additional dependents)"
|
|
W ?131,$C(13) W:EALNE("ULC")="-" ! W EALNE("UL")
|
|
;
|
|
W !,"1. SPOUSE'S NAME (Last, First, Middle Name)",?49,"|2. CHILD'S NAME (Last, First, Middle Name)",?94,"|2A. CHILD'S RELATIONSHIP TO YOU"
|
|
W !?3,$P(@EASD@(1),U),?49,"| ",@EASD@(2),?94,"| ",@EASD@(9)
|
|
W ?131,$C(13) W:EALNE("ULC")="-" ! W EALNE("UL")
|
|
;
|
|
W !,"1A. SPOUSE'S MAIDEN NAME",?49,"|2B. CHILD'S SOCIAL SECURITY NUMBER",?94,"|2C. DATE CHILD BECAME YOUR DEPENDENT"
|
|
W !?4,$P(@EASD@(1),U,2),?49,"| ",@EASD@(7),?94,"| ",@EASD@(11)
|
|
W ?131,$C(13) W:EALNE("ULC")="-" ! W EALNE("UL")
|
|
;
|
|
W !,"1B. SPOUSE'S SOCIAL SECURITY NUMBER ",@EASD@(3),?66,"|2D. CHILD'S DATE OF BIRTH (mm/dd/yyyy) ",@EASD@(5)
|
|
W ?131,$C(13) W:EALNE("ULC")="-" ! W EALNE("UL")
|
|
;
|
|
W !,"1C. SPOUSE'S DATE OF BIRTH (mm/dd/yyyy)",?44,"|1D. DATE OF MARRIAGE (mm/dd/yyyy)",?84,"|2E. WAS CHILD PREMANENTLY AND TOTALLY"
|
|
W !?4,@EASD@(4),?44,"| ",@EASD@(10),?84,"| DISABLED BEFORE THE AGE OF 18? ",@EASD@(14)
|
|
W ?131,$C(13) W:EALNE("ULC")="-" ! W EALNE("UL")
|
|
;
|
|
W !,"1E. SPOUSE'S ADDRESS AND TELEPHONE NUMBER (Street, City, State, ZIP)",?84,"|2F. IF CHILD IS BETWEEN 18 AND 23 YEARS"
|
|
W !?4,$P(@EASD@(6),U),?84,"| OF AGE, DID CHILD ATTEND SCHOOL LAST"
|
|
W !?4,$P(@EASD@(6),U,2),?84,"| CALENDAR YEAR? ",@EASD@(15)
|
|
W !?4,@EASD@(8),?84,"|"
|
|
W ?131,$C(13) W:EALNE("ULC")="-" ! W EALNE("UL")
|
|
;
|
|
W !,"3. IF YOUR SPOUSE OR DEPENDENT CHILD DID NOT LIVE WITH YOU LAST",?65,"|2G. EXPENSES PAID BY YOUR DEPENDENT CHILD FOR COLLEGE, VOCATIONAL"
|
|
W !?3,"YEAR, ENTER THE AMOUNT YOU CONTRIBUTED TO THEIR SUPPORT",?65,"| REHABILITATION OR TRAINING (e.g., tuition, books, materials)"
|
|
W !?6,"SPOUSE $ ",$P(@EASD@(12),U),?35,"CHILD $ ",$P(@EASD@(12),U,2),?65,"|",?73,"$ ",@EASD@(13)
|
|
W ?131,$C(13) W:EALNE("ULC")="-" ! W EALNE("UL")
|
|
Q
|
|
;
|
|
INC ; Print out VA 10-10EZ Section VII, Gross Annual Income information
|
|
;
|
|
I $G(EASDG),+@EASD@(999) W !?6,"SECTION VII - PREVIOUS CALENDAR YEAR GROSS ANNUAL INCOME OF VETERAN, SPOUSE AND DEPENDENT CHILDREN (INCOME YEAR: ",@EASD@(999),")"
|
|
E W !?17,"SECTION VII - PREVIOUS CALENDAR YEAR GROSS ANNUAL INCOME OF VETERAN, SPOUSE AND DEPENDENT CHILDREN"
|
|
W ?131,$C(13) W:EALNE("ULC")="-" ! W EALNE("UL")
|
|
;
|
|
W !?69,"|",?76,"VETERAN",?90,"|",?97,"SPOUSE",?110,"|",?117,"CHILD 1"
|
|
W ?131,$C(13) W:EALNE("ULC")="-" ! W EALNE("UL")
|
|
;
|
|
W !,"1. GROSS ANNUAL INCOME FROM EMPLOYMENT (e.g., wages, bonuses, tips)",?69,"| $ ",$P(@EASD@("2C1"),U),?90,"| $ ",$P(@EASD@("2C1"),U,2),?110,"| $ ",$P(@EASD@("2C1"),U,3)
|
|
W !?3,"EXCLUDING INCOME FROM YOUR FARM, RANCH, PROPERTY OR BUSINESS",?69,"|",?90,"|",?110,"|"
|
|
W ?131,$C(13) W:EALNE("ULC")="-" ! W EALNE("UL")
|
|
;
|
|
W !,"2. NET INCOME FROM YOUR FARM, RANCH, PROPERTY OR BUSINESS",?69,"| $ ",$P(@EASD@("2C3"),U),?90,"| $ ",$P(@EASD@("2C3"),U,2),?110,"| $ ",$P(@EASD@("2C3"),U,3)
|
|
W ?131,$C(13) W:EALNE("ULC")="-" ! W EALNE("UL")
|
|
;
|
|
W !,"3. LIST OTHER INCOME AMOUNTS (e.g., Social Security, compensation,",?69,"| $ ",$P(@EASD@("2C2"),U),?90,"| $ ",$P(@EASD@("2C2"),U,2),?110,"| $ ",$P(@EASD@("2C2"),U,3)
|
|
W !?3,"pension, interest, dividends). EXCLUDING WELFARE",?69,"|",?90,"|",?110,"|"
|
|
W ?131,$C(13) W:EALNE("ULC")="-" ! W EALNE("UL")
|
|
Q
|
|
;
|
|
EXP ; Print out VA 10-10EZR Section VIII, Deductible Expense Information
|
|
;
|
|
I $G(EASDG),+@EASD@(999) W !?26,"SECTION VIII - PREVIOUS CALENDAR YEAR DEDUCTIBLE EXPENSES (INCOME YEAR: ",@EASD@(999),")"
|
|
E W !?37,"SECTION VIII - PREVIOUS CALENDAR YEAR DEDUCTIBLE EXPENSES"
|
|
W ?131,$C(13) W:EALNE("ULC")="-" ! W EALNE("UL")
|
|
;
|
|
W !,"1. NON-REIMBURSED MEDICAL EXPENSES PAID BY YOU OR YOUR SPOUSE (e.g., payments for doctors, dentists,",?110,"| $ ",@EASD@("2D1")
|
|
W !,"medications, Medicare, health insurance, hospital and nursing home)",?110,"|"
|
|
W ?131,$C(13) W:EALNE("ULC")="-" ! W EALNE("UL")
|
|
;
|
|
W !,"2. AMOUNT YOU PAID LAST CALENDAR YEAR FOR FUNERAL AND BURIAL EXPENSES FOR YOUR DECEASED SPOUSE OR DEPENDENT",?110,"| $ ",@EASD@("2D2")
|
|
W !,"CHILD (Also enter spouse or child's information in Section V.)",?110,"|"
|
|
W ?131,$C(13) W:EALNE("ULC")="-" ! W EALNE("UL")
|
|
;
|
|
W !,"3. AMOUNT YOU PAID LAST CALENDAR YEAR FOR YOUR COLLEGE OR VOCATIONAL EDUCATIONAL EXPENSES (e.g., tuition,",?110,"| $ ",@EASD@("2D3")
|
|
W !,"books, fees, materials). DO NOT LIST YOUR DEPENDENTS' EDUCATIONAL EXPENSES.",?110,"|"
|
|
W ?131,$C(13) W:EALNE("ULC")="-" ! W EALNE("UL")
|
|
Q
|