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