VistA-internationalization/TranslationSpreadsheets/WV-DIALOG-0063.txt

English	French	Notes	Complete/Exclude
SUM OF ALL LINES FIXED AND LIQUID ASSETS			
TOTAL ASSETS			
Current income, e.g. gross income (including, but not limited 			
to, wages and income from			
a business, bonuses, tips, severance pay, accrued benefits, 			
cash gifts)			
Social Security Retirement/Disability			
Interest/Dividends (i.e., interest income, standard dividend 			
income from non tax deferred			
Retirement and Pension income			
Civil Service Retirement			
US Railroad Retirement			
VA Pension			
Spouse VA disability/compensation			
Unemployment Benefits/Compensation			
Other compensation, e.g. Workers Compensation and Black Lung			
Court Mandated (e.g. alimony, child support) (Veteran and Spouse)			
Other Income (i.e., inheritance amounts, tort settlement 			
SECTION VI - EXPENSES			
1. Education (veteran, spouse or dependent)			
2. Funeral and Burial (spouse or child)			
5. Car Payment Only (excludes gas, insurance, parking fees)			
7. Non-reimbursed medical expenses			
8. Court-ordered payments			
9. Insurance (exclude life insurance)			
10. Taxes (on any amount include in gross income, property, personal)			
SECTION 			
 - CONSENT FOR ASSIGNMENT OF BENEFITS			
I hereby authorize the Department of Veterans Affairs to disclose any such history, diagnostic and treatment information from my			
medical records to the contractor of any health plan contract under which I am apparently eligible for medical care or payment of			
the expense of care or to any other party against whom liability is asserted.  I understand that I may revoke this authorization at			
any time, except to the extent that action has already been taken in reliance on it.  Without my express revocation, this consent			
will automatically expire when all action arising from VA's claim for reimbursement from my medical care has been completed.			
I authorize payment of medical benefits to VA for any services for which payment is accepted.			
 - CONSENT AND AGREEMENT TO MAKE COPAYMENTS			
has received a copy of the Privacy Act Statement and agrees to make appropriate copayments.			
I certify the foregoing statement(s) are true and correct to the best of my knowledge and belief and agree to make the applicable			
copayment for extended care services as required by law.			
Additional Comments:			
This output requires a 132 column printer.			
1010EC PRINT			
APPLICATION FOR EXTENDED CARE SERVICES			
SECTION I - GENERAL INFORMATION			
APPLICATION FOR EXTENDED CARE SERVICES, Continued			
| Social Security Number			
VA FORM 10-10EC DEC 			
1. Primary Residence (Market value minus mortgages or liens. 			
Exclude if veteran receiving only			
non-institutional extended care services or spouse or dependent residing in community. If the			
veteran and spouse maintain separate residences, and the veteran is receiving institutional			
(inpatient) extended care services, include value of the veteran's primary residence.)			
This would			
include a second home, vacation home, rental property.)			
3. Vehicle(s) (Value minus outstanding lien. Exclude primary vehicle if veteran 			
institutional (inpatient) extended care services, include value of veteran's primary vehicle.)			
1. Cash, Amount in Bank Accounts (e.g., checking and savings accounts, certificates 			
of deposit			
individual retirement accounts, stocks and bonds.)			
2. Value of Other Liquid Assets (e.g., art, rare coins, stamp collections, collectibles)  Minus			
the amount you owe on these items. Exclude household effects, clothing, jewelry, and personal			
items if veteran receiving only non-institutional extended care services or spouse or			
dependent residing in the community.			
 SUM OF ALL LINES FIXED AND LIQUID ASSETS			
|    TOTAL ASSETS			
SECTION VI - CURRENT GROSS INCOME OF VETERAN AND SPOUSE			
1. Gross annual income from employment (e.g., wages, bonuses, tips, severance pay			
accrued benefits)			
2. Net income from your farm/ranch, property or business.			
3. List other income amounts (e.g., Social Security, retirement and pension, 			
interest, dividends)  Refer to instructions.			
SECTION VII - DEDUCTIBLE EXPENSES			
1. Educational expenses of veteran, spouse or dependent (e.g., tuition, books, fees, material, etc.)			
2. Funeral and Burial (spouse or child, amount you paid for funeral and burial expenses, including prepaid			
3. Rent/Mortgage (monthly amount or annual amount)			
4. Utilities (calculate by average monthly amounts over the past 12 months)			
5. Car Payment for one vehicle only (exclude gas, automobile insurance, parking fees, repairs)			
6. Food (for veteran, spouse and dependent)			
7. Non-reimbursed medical expenses paid by you or spouse (e.g., copayments for physicians, dentists,			
medications, Medicare, health insurance, hospital and nursing home expenses)			
8. Court-ordered payments (e.g., alimony, child support)			
9. Insurance (e.g., automobile insurance, homeowners insurance) Exclude life insurance			
10. Taxes (e.g., personal property for home, automobile) Include average monthly expense for taxes paid on			
income over the past 12 months.			
SECTION X - PAPERWORK PRIVACY ACT INFORMATION			
The Paperwork Reduction Act of 1995 requires us to notify you that this information collection is in accordance with the clearance			
requirements of section 3507 of the Paperwork Reduction Act of 1995. We may not conduct or sponsor, and you are not required to			
respond to, a collection of information unless it displays a valid OMB number. We anticipate that the time expended by all			
individuals who must complete this form will average 90 minutes. This includes the time it will take to read instructions, gather			
the necessary facts and fill out the form. If you have comments regarding this burden estimate or any other aspect of this			
collection, call 202.273.8247 for mailing information on where to send your comments.			
Privacy Act Information:  The VA is asking you to provide the information on this form under Title 38, United States Code,			
sections 1710, 1712, 1722 and 1729 in order for VA to determine your eligibility for extended care benefits and to establish			
financial eligibility, if applicable, when placed in extended care services. The information you supply may be verified through a			
computer-matching program. VA may disclose the information that you put on the form as permitted by law. VA may make a			
routine use			
 disclosure of the information as outlined in the Privacy Act systems of records notices and in accordance with the			
VHA Notice of Privacy Practices. You do not have to provide the information to VA, but if you don't, VA will be unable to process			
your request and serve your medical needs. Failure to furnish the information will not have any affect on any other benefits to			
which you may be entitled. If you provide VA your Social Security Number, VA will use it to administer your VA benefits. VA may			
also use this information to identify veterans and persons claiming or receiving VA benefits and their records, and for other			
purposes authorized or required by law.			
Patient is not a Veteran.			
Date of LTC Copay Test: 			
The date of test must be after the date of the last test on 			
An LTC Copay Test already exists on 			
Are you sure you want to add a new test			
LTC COPAY 			
   Use the 'EASEC 			
TEST EDIT' Option.			
TEST VIEW' Option.			
Is veteran EXEMPT from LTC copayments			
Enter either 'Y' or 'N'.			
Answer 'Yes' if the veteran is exempt from LTC copayments			
for a reason other than low income.			
Reason for Exemption			
A reason for exemption must be entered.  LTC Copay Test cannot be added.			
Veteran is NOT EXEMPT from Long Term Care copayments based			
on last year's income and must complete a 10-10EC form.			
Enter in this field the annual amount of Social Security			
received during the current calendar year.			
A monthly amount can be entered with an '*' after it.			
Enter in this field the annual amount of U.S. Civil Service			
Enter in this field the annual amount of Military Retirement			
Enter in this field the annual amount of Other Retirement received			
during the current calendar year.  This includes company, state,			
Enter in this field the annual amount of Gross Income received during			
the current year.  This includes, but is not limited to, wages and			
income from a business, bonuses, tips, severance pay, accrued			
benefits, cash gifts.			
Enter in this field the annual amount of Net Income received during			
the current calendar year from the operation of a farm, ranch,			
property or business.			
Enter in this field the annual amount of Interest and Dividend			
Income received during the current calendar year (i.e., interest			
income, standard dividend income from non tax deferred annuities).			
Enter in this field the annual amount of Workers Compensation or			
Black Lung Benefits received during the current calendar year.			
Enter in this field the annual amount of All Other Income received			
during the current calendar year, including retirement and pension			
income, Social Security Retirement and Social Security Disability			
income, compensation benefits such as unemployment, Workers and			
Black Lung, or VA disability.  Also cash gifts, court mandated			
payments, inheritance amounts, tort settlement payments, interest			
and dividends, including tax exempt earnings and distributions from			
Individual Retirement Accounts (IRAs) or annuities.			
received during the current calendar year (i.e., inheritance amounts,			
tort settlement payments).			
Enter in this field the total amount of unreimbursed medical expenses			
paid by the veteran during the current calendar year.  The expenses			
can be for the veteran or for members of the veteran's family.			
Reportable medical expenses include amounts paid for the following:			
fees of physicians, dentists, and other providers of health services;			
hospital and nursing home fees; medical insurance premiums (including			
the Medicare premium); drugs and medicines; eyeglasses; any other			
expenses that are reasonable related to medical care.  The expenses			
must actually have been paid by the veteran.  Do not list expenses			
which have not been paid or which have been paid by someone other			
than the veteran.  Do not list expenses which the veteran has paid if			
the veteran expects to receive reimbursement from insurance or some			
other source.			
calendar year for funeral or burial expenses of the veteran's			
spouse or child, or pre-paid arrangements for the veteran.			
Do not report amounts paid for funeral or burial expenses of other			
relatives such as parents, siblings, etc.			
Enter in this field the total amount paid by the veteran for			
educational expenses during the current calendar year.  This			
includes educational expenses for the veteran, spouse and children.			
Educational expenses are tuition, fees, and books if enrolled in a			
program of education.			
Enter in this field cash and amounts in bank accounts.  This			
includes checking accounts, savings accounts, money markets,			
interest, dividends from IRA, 401K's, and other tax deferred			
Enter in this field the current value of stocks, bonds, mutual			
funds, SEP's, and other retirement accounts (e.g., IRA, 401K,			
annuities, self-employed person).			
 has no LTC copay (10-10EC) tests on file.			
This LTC Copay Test (10-10EC) is uneditable and cannot be deleted.			
Display test			
    <OK, nothing deleted!>			
  <LTC Copay Test deleted.>			
Pat ID: 			
  LTC Copay Test Date   Status: 			
Source: 			
EASEC DEPENDENTS			
Cannot edit when viewing a LTC copay test.			
Not a LTC copay test - use LTC copay test options.			
 as a dependent to the LTC copay test.			
Not applicable for LTC copay test			
Married This Year: 			
Legally Separated: 			
Spouse Residing in Community: 			
Living with Spouse: 			
Dependent Residing in Community: 			
Dependent Living with You: 			
EASEC EXPAND PROFILE			
Select DATE OF LTC COPAY TEST: 			
Warning: Uneditable LTC Copay test.  The source of this test is 			
Would you like to view the LTC Copay test or print the 10-10EC			
Enter a date that is less than or equal to today.			
Enter the date of the LTC Copay Test.			
Are you sure you want to change the date of the LTC Copay Test			
must complete a 10-10EC form.			
Report of LTC Copayment Tests			
Enter 1 or 2			
Indicate whether the report should include:			
(1) a list of veterans whose LTC Copayment Test is pending expiration (i.e.,			
the anniversary date of the test is approaching) within a user-specified			
number of days, or			
(2) a list of veterans whose LTC Copayment Test has already expired (i.e.,			
the anniversary date of the test has passed) since a user-specified date.			
Enter number of days to report			
Enter a start date			
Sort report by Name or Date			
Indicate whether the report should be sorted by the			
Veteran's Name or the LTC Copay Test Anniversary Date			
Report Cancelled!			
LTC COPAY TESTS			
Report 			
Queued!			
Cancelled!			
*** No records to print ***			
VETERANS WITH LONG TERM CARE COPAYMENT TESTS THAT			
ARE PENDING EXPIRATION IN 			
HAVE EXPIRED SINCE 			
SORTED BY 			
REPORT DATE: 			
LTC Test			
Veteran's Name			
Anniversary Date			
The income threshold check could not be completed due to an error.			
Means Test			
LTC Copay Exemption Test			
The previous year's financial information is not on file for this veteran.			
 is required.			
 at this time			
Report of Calculated Long Term Care Copayments			
No LTC Copayment Test on file for this veteran!			
Copayment rates for LTC are not available at this time.			
The LTC Copayment Test is incomplete!			
This veteran is Exempt from LTC copayments!			
This LTC Copayment Test contains an invalid status!			
Enter the LTC Admission Date			
Enter the admission date for the current institutional			
Long Term Care episode.			
Enter the Report Start Date (Month/Year)			
Enter the starting date for the report in the format month/year (e.g. 9/03).			
The report will print 12 months of copayments starting with the			
month and year entered.			
Report Start Date cannot be before LTC Admission Date!			
LTC Copay Calculation Report			
SPOUSE RESIDING IN THE COMMUNITY			
*** DECLINED TO PROVIDE INCOME INFORMATION -- AGREED TO PAY COPAYMENTS ***			
*** VETERAN IS INELIGIBLE FOR LTC SERVICES -- REFUSED TO SIGN 10-10EC ***			
LTC COPAY TEST DATE: 			
LTC ADMISSION DATE: 			
LTC COPAYMENT CALCULATION			
FOR DAYS 1-180  			
FOR DAYS 181+   			
TOT ASSETS    			
TOT INCOME    			
TOT EXPENSES  			
TOT ALLOWANCE 			
CALC COPAY    			
MAX COPAY     			
VET COPAY     			
LONG TERM CARE ESTIMATED COPAYMENTS FOR 			
NON-			
INSTITUTIONAL SERVICES			
TOTAL INCOME - TOTAL EXPENSES - TOTAL ALLOWANCE			
(TOTAL ASSETS + TOTAL INCOME) - TOTAL EXPENSES - TOTAL ALLOWANCE			
(TOTAL ASSETS + TOTAL INCOME) - TOTAL ALLOWANCE			
IMPORTANT NOTICE: The copayment amounts shown in this report are			
based on calculations of the copayment amount for 			
an entire month. The			
copayment amounts will be adjusted to 			
reflect the actual start date of LTC			
services and the 			
copayment exemption for the first 21 days of service. The VET			
COPAY amount is based on the assumption that the veteran 			
will be responsible			
to pay the lesser of EITHER the calculated			
 copayment (CALC COPAY) OR the			
maximum copayment (MAX COPAY).  			
In the event that the calculated copayment			
(CALC COPAY) is a 			
negative figure, the veteran copayment (VET COPAY)			
will be adjusted to zero (0). If the veteran declined to provide			
information, the veteran will be obligated to pay the			
 maximum copayment.			
EXPLANATION OF ASSET SPEND DOWN CALCULATION:			
The veteran's assets are included in the calculation of copayments			
after 180 days of institutional LTC services.  The assets then may			
be reduced each month according to the following formula:			
Single Veteran:			
  TOTAL ASSETS-(VET COPAY-(INCOME-ALLOWANCE))			
Married Veteran (spouse residing in the community):			
  TOTAL ASSETS-(VET COPAY-(INCOME-EXPENSES-ALLOWANCE))			
In other words, the assets will be reduced by the amount of the			
veteran's copayment that is not covered by the veteran's income 			
after all expenses and allowances are subtracted.  If the amount			
of the veteran's income after all expenses and allowances are			
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