308 lines
9.2 KiB
Plaintext
308 lines
9.2 KiB
Plaintext
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English French Notes Complete/Exclude
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Do you wish to return to Screen #9 to enter missing Income Data?
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A means test for this encounter date was not found and may be required!
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Further investigation will be needed.
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Press ENTER to continue
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Patient Requires a means Test
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Primary Means Test Required from '
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SCENI MEANS TEST EDIT
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You do not have the appropriate IEMM Security Key. Contact your supervisor.
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Do you wish to proceed with the means test at this time
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No registrations to print from.
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Registration date/time:
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Enter the date and time, Entry #, or 'L' for the last registration,
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to select the registration you wish to print a 10/10 for.
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This output requires 132 column output to a PRINTER.
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Output to SCREEN will be unreadable.
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FACILITY NOT IDENTIFIED
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APPLICATION FOR MEDICAL BENEFITS
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PRINT
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ENTER 'Y'ES TO PRINT A
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. OTHERWISE ENTER 'N'O.
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NOT APPLICABLE
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SEE ATTACHMENT FOR PAPERWORK REDUCTION INFORMATION AND PRIVACY ACT INFORMATION
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PART I - PATIENT DATA
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1. Type of benefit applied for:
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HOSPITAL/OUTPATIENT TREATMENT^DOMICILIARY CARE^HOSPITAL/OUTPATIENT TREATMENT^OUTPATIENT DENTAL^NURSING HOME CARE
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3. Other names used (Alias)
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4. Social Security Number
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5. Claim Number
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| 6. LOCATION OF CLAIMS FOLDER
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| 7. DATE OF BIRTH
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| 8. PLACE OF BIRTH
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9. PERMANENT ADDRESS
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10. TEMPORARY ADDRESS
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9A. STREET ADDRESS:
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10A. STREET ADDRESS:
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9D. ZIP CODE:
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10D. ZIP CODE:
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9F. HOME TELEPHONE NUMBER:
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10F. HOME TELEPHONE NUMBER:
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11. CONFIDENTIAL ADDRESS
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Not Applicable
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11A. STREET ADDRESS:
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11D. ZIP CODE:
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| 11F. START DATE:
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| STOP DATE:
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11G. Active Confidential Address Categories
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13. MOTHER'S MAIDEN NAME
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16. RELIGIOUS PREFERENCE
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17. DATE OF PREVIOUS CARE
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18. LOCATION OF PREVIOUS CARE
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19. SPINAL CORD INJURY
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PARAPLEGIA-TRAUMATIC
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QUADRIPLEGIA-TRAUMATIC
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PARAPLEGIA-NONTRAUMATIC
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QUADRIPLEGIA-NONTRAUMATIC
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PART II - EMERGENCY CONTACT DATA
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1A. FIRST NEXT OF KIN
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2A. SECOND NEXT OF KIN
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3A. FIRST CONTACT IN AN EMERGENCY
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4A. SECOND CONTACT IN AN EMERGENCY
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C. HOME TELEPHONE NUMBER
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D. WORK TELEPHONE NUMBER
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E. ADDRESS (Number, Street, City, State, ZIP Code)
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Reg Date/Time:
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PRINTED:
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Clerk:
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AUTOMATED VA FORM 10-10
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PART III - APPLICANT/SPOUSE DATA
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1. APPLICANT'S EMPLOYMENT STATUS:
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2. SPOUSE'S EMPLOYMENT STATUS:
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3. APPLICANT INFORMATION
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3B. EMPLOYER (Name, Street Address, City, State, Zip)
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4B. EMPLOYER (Name, Street Address, City, State, Zip)
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3C. WORK TELEPHONE NUMBER:
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4C. WORK TELEPHONE NUMBER:
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NOT ANSWERED
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PART IV - MILITARY SERVICE DATA
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1A. LAST BRANCH OF SERVICE
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1B. LAST SERVICE NUMBER
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1C. LAST DATE OF ENTRY
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1D. LAST DISCHARGE DATE
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1E. DISCHARGE TYPE
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2A. PRIOR BRANCH OF SERVICE
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2B. PRIOR SERVICE NUMBER
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2C. PRIOR DATE OF ENTRY
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2D. PRIOR DISCHARGE DATE
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2E. DISCHARGE TYPE
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3A. PRIOR BRANCH OF SERVICE
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3B. PRIOR SERVICE NUMBER
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3C. PRIOR DATE OF ENTRY
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3D. PRIOR DISCHARGE DATE
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3E. DISCHARGE TYPE
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PART V - ELIGIBILITY STATUS DATA
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1. PATIENT TYPE:
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2. IS NEED FOR MEDICAL CARE RELATED TO AN
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3. IS THE NEED FOR MEDICAL CARE RELATED
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4. IS PATIENT ELIGIBLE FOR MEDICAID:
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ON THE JOB INJURY:
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TO AN ACCIDENT:
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5A. DOES PATIENT HAVE HEALTH INSURANCE
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5B. IF YES, COVERAGE PROVIDED BY:
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COVERAGE:
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PATIENT'S INSURANCE
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SPOUSE'S INSURANCE
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NO ACTIVE (UNEXPIRED) INSURANCE ON FILE FOR THIS APPLICANT
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6. DOES VETERAN HAVE GI
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7. PRIMARY ELIGIBILITY CODE
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8. OTHER ELIGIBILITY CODE
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9. PERIOD OF SERVICE
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INSURANCE:
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10. SERVICE CONNECTED CONDITIONS AS STATED BY APPLICANT:
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10. RATED SERVICE CONNECTED CONDITIONS:
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NO RATED SERVICE-CONNECTED CONDITIONS
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10. SERVICE CONNECTED CONDITIONS:
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NOT APPLICABLE: NOT A SERVICE-CONNECTED APPLICANT
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PART VI - INCOME SCREENING DATA OR ANNUAL INCOME
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1A. CURRENT MARITAL STATUS:
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1B. DATE OF MARRIAGE:
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2A. WAS PATIENT MARRIED OR SEPARATED AT THE END OF LAST CALENDAR YEAR?:
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2B. NAME OF SPOUSE
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2C. SEX OF SPOUSE
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2D. SPOUSE'S SOCIAL SECURITY NO
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2E. SPOUSE'S DATE OF BIRTH
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B. SOCIAL SECURITY NO
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D. DATE OF BIRTH
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F. DEPENDENT AS
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NONE INDICATED
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4. PREVIOUS CALENDAR YEAR (
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) INCOME INFORMATION
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CHECK ALL APPLICABLE BOXES
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11. TOTAL INCOME
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PART VII - INELIGIBLE/MISSING DATA
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1. INELIGIBLE DATE
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2. TWX SOURCE
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3. TWX CITY
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4. TWX STATE
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6. VACO DECISION:
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7. MISSING DATE
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8. TWX SOURCE
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9. TWX CITY
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10. TWX STATE
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1. ELIGIBILITY STATUS
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2. STATUS DATE
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3. STATUS ENTERED BY
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PENDING VERIFICATION
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RE-VERIFY
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4. VERIFICATION METHOD
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5. SERVICE VERIFICATION DATE
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6. RATED DISABILITIES
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SIGNATURE OF APPLICANT OR APPLICANT'S REPRESENTATIVE
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FOR VA USE ONLY
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VA FACILITY NUMBER
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ADMISSION DATE
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AUTHORITY FOR ADMISSION OR TREATMENT
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SUPPLEMENTAL DATA SHEET
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HEALTH SUMMARY
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DRUG PROFILE
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ENCOUNTER FORMS
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No Type Selected. HS will not print
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Select type of Drug Profile
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11. OTHER ELIGIBILITY DATA
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L. SERVICE IN PERSIAN GULF THEATER
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B. PRISONER OF WAR STATUS
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M. DENTAL INJ. |
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TEETH EXTRACTED
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C. EXPOSURE TO AGENT ORANGE
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N. SERVICE CONNECTED
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D. EXPOSURE TO RADIATION
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O. RECEIVING AID & ATTENDANCE
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E. COMBAT SERVICE
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P. RECEIVING HOUSEBOUND
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F. MILITARY DISABILITY
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Q. RECEIVING VA PENSION
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G. VIETNAM SERVICE
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R. RECEIVING VA DISABILITY
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H. LEBANON SERVICE
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S. SERVICE IN SOMALIA
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I. GRENADA SERVICE
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T. SERVICE IN YUGOSLAVIA
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J. PANAMA SERVICE
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U. PURPLE HEART RECIPIENT
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K. PERSIAN GULF SERVICE
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V. VA MONETARY AMOUNT:
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3. Other Name(s):
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NO ALIAS' ON FILE
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NO REMARKS CURRENTLY ENTERED FOR THIS APPLICANT
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5. Fathers Name:
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NOT SPECIFIED
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Mothers Name:
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Mothers Maiden Name:
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6a. Enrollment Clinic(s):
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NOT ACTIVELY ENROLLED IN ANY CLINICS AT THIS TIME
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6b. Future Appointments:
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NO PENDING APPOINTMENTS ON FILE
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7a. Last Admission:
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NO PREVIOUS ADMISSIONS TO THIS FACILITY ON FILE
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LAST ADMISSION PTF DATA NO LONGER STORED
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7b. Discharge Diagnosis(es):
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NO DIAGNOSES ON FILE FOR THIS ADMISSION PERIOD YET
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7c. Admit Diagnosis:
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7d. Diagnosis Responsible for Greatest Length of Stay:
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8. Eligibility Status:
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PENDING RE-VERIFICATION
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UNKNOWN OR NONE
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| Status Date:
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Verification Method:
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ELIGIBLE APPLICANT -- NOT APPLICABLE
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Ineligible Date:
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CITY UNKNOWN
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STATE UNKNOWN
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VARO DECISION UNKNOWN
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| TWX Source:
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TWX City:
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| TWX State:
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VARO Decision:
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9. Vietnam Service:
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From:
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To :
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Agent Orange:
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Reg :
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Exam :
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Reg #:
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Loc:
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ION Radiation:
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Method:
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Prisoner of War:
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Where:
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Combat:
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Purple Heart:
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Status:
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Remarks:
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10. Next of Kin, Address and Zip Code:
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Name:
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KOREAN DMZ
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NAGASAKI/HIROSHIMA
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NUCLEAR TESTING
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NUCLEAR TESTING & NAGASAKI/HIROSHIMA
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STREET ADDRESS UNKNOWN
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CITY STATE UNKNOWN
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GLOBAL SUBSCRIPT LOCATION
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Unknown/Invalid pointer, DD(
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GLOBAL NAME
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Cannot convert the
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in the
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File 11 and 13 Conversion Problem list
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MARITAL STATUS (#11) File Conversion Problems:
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RELIGION (#13) File Converion Problems:
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No problems
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Pointer File/Subfile^Field^Problem Description
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DG*5.3*172
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DGY(
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File 11 and 13 Conversion Problems
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*** Conversion is not necessary! ***
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Uninstalling patch...
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*** Not all non-standard entries have been mapped...see DG172 options ***
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*** Job appears to already be running! ***
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Are you sure you want to start the conversion process
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Marital/Religion File Conversion
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Are you sure you want to stop the background conversion process
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*** Job will stop soon ***
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*** Conversion process is NOT running! ***
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RGPR PRE-IMP MENU
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DG172
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RELIGION/MARITAL STATUS REINDEX
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Reindex Religion and Marital Status file xrefs ...
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Setting up files that need to be converted...
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Setting up standard/non-standard mapping file...
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You can not re-start this process!
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*** No mapping necessary! ***
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Select Non-Standard
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Marital Status:
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Religion:
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Religion/Marital Status Conversion
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Conversion Finished
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DG172(1,
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Conversion *NOT* Finished
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The conversion process appears to have been stopped.
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To finish the conversion process, restart by using
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the 'Begin Religion/Marital Status Conversion' option
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on the CIRN Pre-Implementation Menu.
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Marital Status
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Religion
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File Non-Standard Entries:
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All non-standard entries listed above have been removed
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from their respective files.
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Entry:
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repointed to:
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Starting post-install process...
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Post-install process has completed.
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total records have been identified and corrected.
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Report cancelled!
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Means Test Update Report
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Updated Means Test Listing
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Run Date:
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Veteran Name
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Veteran SSN
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Year
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Old Status
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New Status
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Income Year
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Old Means Test Status
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#################### #################### ####################
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#################### #################### ####################
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#################### #################### ####################
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#################### #################### ####################
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#################### #################### ####################
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