308 lines
13 KiB
Plaintext
308 lines
13 KiB
Plaintext
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English French Notes Complete/Exclude
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Elig. Code:
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Amt.: $
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House Bound:
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Tot.Ann. VA Check Amt.: $
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Amount Earned Annual Income (SPOUSE):
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Amount of Annual Social Security (SPOUSE):
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Type of other Annual Retirement (SPOUSE):
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Amount of other Annual Retirement (SPOUSE):
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Amount of other Annual Income (SPOUSE):
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Amount of Earned Annual Income (PAYEE):
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Amount Annual
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Soc. Sec. (PAYEE):
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Receiving Soc. Sec. (PAYEE):
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Other Annual
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Retirement (PAYEE):
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Amount Other Annual
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Income (PAYEE):
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****** HINQ Upload/edit ******
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Verification screen only
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Patient file
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BIRLS ONLY
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BIRLS/C&P
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NOT UPDATED
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HINQ Response
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** BIRLS indicates Patient is deceased.
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** VA Monetary Ben. Terminated - Means Test Required **
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Man.ver.
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Not issued
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Pat. Type:
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Elig. Stat.:
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Vet. Y/N:
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Stat. Date:
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Disab. Ind.:
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Elig. code:
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WARNING: Error Indicators for
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.. Alert found.
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Screen
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HINQ Update .
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another request pending, alert cleared
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This patient data is being edited by another user
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Checking the alerts .
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. need more changes
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LOAD/EDIT Screen
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SC D
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HINQ has data not in patient file `
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Patient file has data not in HINQ `
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HINQ, Patient file are different `
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Screen (
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Do you wish to acknowledge inconsistencies and clear this Alert ?
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If the patient file has data that should not be updated by HINQ, this Alert
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can be acknowledged and cleared by entering 'Y'es. Otherwise, just continue
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Press RETURN to continue,'Y'es to acknowledge, '^' to exit:
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Alert will be cleared
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Alerts have been cleared
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3-SC Disabilities
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3+SC Disabilities
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Pension
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Disability
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5?SC Combined %
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SC LESS THAN
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2?Folder Location
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5?VA Check/Net Award
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Entering a request in the HINQ suspense file...
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Checking alert data
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Clear corrected HINQ alerts
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Clearing corrected HINQ alerts
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No alerts cleared...
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IOINHI;IOINLOW;IOBON;IOBOFF
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Is this the patient to update (YES, NO, IGNORE, DISPLAY, ALERT)? YES//
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You are not processing an Alert, 'A'lert update and display not available.
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'Y'es, Will continue with this patient
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'N'o, Go next patient
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'I'gnore, Patient will NOT appear in ALL option until reHINQ
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'D'isplay will show you the HINQ mail message.
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'A'lert, will update and display the Alert if processing alerts
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'^' to quit
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* This option will print out a report, identical to the mail *
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* messages, of the patients in the suspense file with a *
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* successful HINQ request. *
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BIRLS only response and the 'Diagnostic Verified Indicator' is NO.
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Verify SC at folder location:
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No updating allowed.
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Your version of MAS is NOT greater than 5.1, thus the Unemployable field
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is not in your patient file. No uploading of this field allowed.
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to CONTINUE,
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to QUIT,
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to update:
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HINQ data does NOT seem right.
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Data appears to be missing for
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Please re-HINQ for this patient.
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30 days or greater
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DVBWCHK...This init should run after PIMS v5.3 is installed
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<<PROGRAMMER NOT DEFINED>>
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*** Updating DISABILITY CONDITION file (#31)
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per VA circular 21-95-2, dated Feb. 1, 1995
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The Disability Condition file (31) update has finished.
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disability codes were added.
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0-DAY LETTER
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Updating '0-DAY LETTER' in the EAS MT LETTER File (#713.3)
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According to our records you have not responded to our previous requests
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to complete the financial section of VA Form 10-10EZ, Application for
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Health Benefits. This is to inform you that your current financial
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assessment (means test) has expired.
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How Does This Affect Your Eligibility for Cost Free Care?
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o We do not have a current means test for you on file as is required to
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determine your eligibility for either cost-free care or reduced
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inpatient copayments.
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How Does This Affect Your Enrollment?
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o We are unable to determine your priority for enrollment in the VA
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health care system.
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What Do You Need To Do?
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o Complete, sign and return a new VA Form 10-10EZ, including the
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financial section.
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o Read the enclosed VA Form 4107VHA, Your Rights to Appeal our Decision.
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If you disagree with our decision, you or your representative may
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complete a Notice of Disagreement and return it to the Enrollment
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Coordinator or Health Benefits Advisor at your local VA health care
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What If You Have Questions?
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DGNEW(
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NOTE: An error occurred when updating the 0-DAY LETTER
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Please contact the VistA Help Desk.
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30-DAY LETTER
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Updating '30-DAY LETTER' in the EAS MT LETTER File (#713.3)
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Each year VA requires most nonservice-connected veterans and 0% service-
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connected veterans to complete a financial assessment (means test). Our
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records show that your annual means test is due.
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As of this date we have not received the updated financial income
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information we requested in a previous letter.
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What Does This Mean To You?
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o An updated means test is needed to determine your ability to pay
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copayments for your medical care and medications and your priority for
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enrollment in the VA health care system.
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o Failure to complete the means test by the anniversary date will cause
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your priority for enrollment in the VA health care system to lapse.
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o Complete and sign the enclosed Financial Assessment portion of the
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enclosed VA Form 10-10EZ, Application for Health Benefits, reporting
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income and assets for the previous calendar year.
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o Return the completed and signed form in the enclosed envelope before
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your means test anniversary date.
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o When you report to your next health care appointment, bring your health
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insurance card so we may update your health insurance information.
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o Notify us if you feel you received this letter in error.
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60-DAY LETTER
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Updating '60-DAY LETTER' in the EAS MT LETTER File (#713.3)
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o Complete and sign the Financial Assessment portion of the enclosed VA
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Form 10-10EZ, Application for Health Benefits, reporting income and
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assets for the previous calendar year.
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Pre-Installation Complete, the EAS MT Letters have been updated.
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*** Updating EAS MT LETTERS file(#713.3)***
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*** Updating 0-DAY LETTER ***
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*** 0-DAY LETTER not updated ***
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*** Updating 30-DAY LETTER ***
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*** 30-DAY LETTER not updated ***
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*** Updating 60-DAY LETTER ***
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*** 60-DAY LETTER not updated ***
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Pre-scan for un-flagged 0-day letters?
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Pre-scan will provide the number of records which will have the 0-day
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Flag-to-Print flag set to 'YES' when this routine is run in the conversion mode.
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Enter 'YES' to pre-scan, 'NO' to convert the 0-day print flags
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Beginning scan for un-flagged 0-day letters
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records scanned
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will have
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the 0-day flag set to print
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SITE
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IS NOT A DCD PILOT SITE
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POST-INSTALLATION COMPLETE
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EAS*1*20 POST-INSTALL
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EAS*1*20 POST INSTALL TASK #
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QUEUED TO RUN
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PATCH EAS*1*22 POST INSTALL
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EAS MT LETTERS
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Post-Install was not tasked off
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Post-Install tasked: [
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Post Install - EAS*1*22
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G.EAS MTLETTERS
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PATCH EAS-1-22
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Entries were removed from the EAS MT LETTER STATUS File (#713.2)
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which did not have a valid pointer to the EAS MT PATIENT STATUS
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File (#713.1). The entries removed were for the processing dates
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listed below. This is provided as information only.
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Date Processed
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Records Removed
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The following patients in the EAS MT PATIENT STATUS File (#713.1)
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do not have a corresponding entry in the EAS MT LETTER STATUS File (#713.2).
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You can try re-generating the Means Test Letter dates for these
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patients by running the REGEN procedure from the post-install
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routine by entering 'D REGEN^EAS122PT' at the programmer prompt.
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See the Patch Instructions for more details.
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Re-generate Means Test Letter Dates for patients
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identified in patch EAS*1*22 cleanup?
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- Patient Merge Cleanup Process
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- PATIENT MERGE CLEANUP
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EAS*1.0*
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: PATIENT MERGE CLEANUP - PROCESS STOPPED BY USER
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: PATIENT MERGE CLEANUP - SUMMARY REPORT
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EAS MT 30 DAY LETTER PRINT
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** Adding a new entry to LTC CO-PAY EXEMPTION file (#714.1).
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LTC IS SERVICE RELATED - COMBAT VET ELIGIBLE
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already exists in file #714.1.
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not added to file #714.1
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*** Updating LTC COPAY EXEMPTION (File #714.1) ***
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- Modifying entry #11
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ERROR: Entry #11 not updated
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.01///LTC RELATED TO HOSPICE CARE
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- Modifying entry #2
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ERROR: Entry #2 not updated
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.01///INCOME (LAST YEAR) BELOW LTC THRESHOLD
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- Adding entry #12
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INCOME (CURRENT YEAR) BELOW LTC THRESHOLD
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The Post Install will now process through PATIENT (#2) file
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to determine User Enrollee status for each Veteran by checking
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inpatient/outpatient encounter for current fiscal year, any
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future appointments and any fee basis authorizations.
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EAS*1*25
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USER ENROLLEE INITIAL DETERMINATION PROCESS
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User Enrollee initial determination process was completed in previous run.
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is currently running User Enrollee determination
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process. Duplicate process cannot be started.
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CURRENT IEN
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by the user. Please restart the process by using the following
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command at the programmer prompt:
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Post install process for initial User Enrollee determination is completed.
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GMTII - USER ENROLLEE INITIAL DETERMINATION PROCESS
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NAIK.CHINTAN@FORUM.VA.GOV
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Site Station number:
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Site Name:
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Process started at :
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Process completed at :
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Total Veterans processed :
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Total Veterans with UE status:
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PATIENT ADDRESS INQUIRY
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*** Address could not be determined ***
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*** No Address On File For This Patient ***
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Patient Address:
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UNKNOWN STREET ADDRESS
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UNKNOWN CITY
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UNKNOWN STATE
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Bad Address Indicator:
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Address Change Date:
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Address Change Source:
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Address Change Site:
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LEGALLY SEPARATED
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EXPENSE(408.21,
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Answer Yes or No where applicable (Otherwise provide the requested information)
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3. Are You Eligible for Medicaid?
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|3A. Are You Enrolled in Medicare Part A (Hospital Insurance)
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|3B. Effective Date (If
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4. Are You Enrolled in Medicare Part B (Medical Insurance)
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|4A. Effective Date (If
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|4B. Medicare Claim Number
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SECTION II - INSURANCE INFORMATION
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5. Are You Covered By Health Insurance (including coverage through a spouse)? (If
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, provide the following information for
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all insurance company(s) providing coverage to you.)
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. Name of Insurance Company
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A. Address of Insurance Company
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B. Phone Number of Insurance Company
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C. Name of Policy Holder
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D. Relationship of Policy Holder
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E. Policy Number
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F. Group Name and/or Number
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SECTION III - SPOUSE/DEPENDENT INFORMATION
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9. Current Marital Status
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9B. Spouse Residing in the Community?
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|9C. Spouse's Social Security Number
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9A. Spouse Residing in the Community?
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|9B. Spouse's Social Security Number
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A. Dependent's Date of Birth
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B. Dependent's Social Security Number
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C. Dependent Residing in the Community?
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We need to collect information regarding income, assets, and
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expenses for you and your spouse. If you do not wish to provide this
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information you must sign agreeing to make copayments and will
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be charged the maximum copayment amount for all services. See the
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top of page 2, read, sign, and date.
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I do not wish to provide my detailed financial information.
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I understand that I will be assessed the maximum copayment amount for
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extended care services and agree to pay the applicable VA copayment as required by law.
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Signature
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SECTION IV - FIXED ASSETS (VETERAN AND SPOUSE)
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1. Residence (Market value minus any outstanding mortgage or
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lien - exclude if veteran
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receiving only non-institutional services or spouse or
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dependent residing in community).
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2. Other Residences/Land/Farm or Ranch (Market value minus any
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outstanding mortgage or lien)
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3. Vehicle(s)* (Value minus any outstanding lien - exclude if veteran is
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receiving only
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non-institutional services or spouse or dependent residing in community).
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| SUBTOTAL (Sum of lines 1 through 3)
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SECTION V - LIQUID ASSETS (VETERAN AND SPOUSE)
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1. Cash, e.g., interest, dividends from IRA, 401K's and other
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tax deferred annuities
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(including checking, savings, money market, etc.)
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2. Stocks, bonds, mutual funds, SEP's, and other retirement
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annuities, self-employed person)
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3. Other Liquid Assets (Includes such items as stamp or coin
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collections, art work, collectibles
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household furniture and other household goods, clothing, jewelry, and
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personal items
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minus amount owed).
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#################### #################### ####################
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#################### #################### ####################
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#################### #################### ####################
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#################### #################### ####################
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#################### #################### ####################
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