308 lines
11 KiB
Plaintext
308 lines
11 KiB
Plaintext
English French Notes Complete/Exclude
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subtracted is greater than the veteran's copayment then the assets
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will not be reduced.
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Do you wish to edit the LTC copay test
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* VETERAN MAY BE EXEMPT FROM COPAY IF LTC EPISODE IS DUE TO THIS CONDITION.
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Service Branch
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Gulf War
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Env Contam:
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Mil Disab:
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Dent Inj:
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Purple Heart:
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and Spouse
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Residence
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Other Residences/Land/Farm/or Ranch
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Vehicle(s)
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Cash, Stocks, Mutual Funds
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Other Liquid Assets
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Cash
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Stocks, Bonds, Mutual Funds, SEP's
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Current Employment Income
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Income from Farm/Ranch/Business
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Current Income
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Soc. Sec. Retire/Disabil
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Interest/Dividends
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Retirement/Pension Income
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Spouse VA Disabil/Compens
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Unemployment Benefit/Comp
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Other Compensation
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Court Mandated
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Other Income
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Education
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Funeral and Burial
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Rent/Mortgage
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Utilities
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Car Payment Only
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Food
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Non-reimbursed Medical Expenses
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Court-ordered Payments
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Taxes
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LTC copay test cannot be completed.
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...The LTC copay test has been completed with a status of
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Do you wish to complete the LTC copay test
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Does veteran decline to give income information
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Answer 'Y' or 'N'.
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Enter whether the veteran declines to provide current income information.
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An active spouse exists for this LTC copay test. Married should be 'YES'.
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LTC Copay Test Status
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A reason for exemption must be entered for an Exempt status.
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Does the veteran agree to pay copayments
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Enter in this field whether the veteran agrees to pay the
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LTC copayments. The veteran must also sign the 1010-EC form
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agreeing to pay the copayments. If the veteran does not agree
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to pay the copayments, the veteran becomes ineligible to
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receive extended care services.
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PRINT 10-10EC
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Veteran is EXEMPT from Long Term Care copayments.
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Reason for Exemption:
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ERROR: COULD NOT UPDATE LTC COPAY TEST
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LTC COPAY TEST FOR
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LTC Copayment Status:
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Last Test:
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**NEW TEST REQUIRED**
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Patient INELIGIBLE to Receive LTC Services -- Did Not Agree to Pay Copayments
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Reason:
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Assets:
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Agrees to Pay Copayments:
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NO *INELIGIBLE*
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Comment(s):
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** DETAILED LTC COPAY TEST INCOME INFORMATION IS NOT
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REQUIRED **
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AVAILABLE **
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** LTC COPAY TEST IS NO LONGER REQUIRED, INCOME INFORMATION MAY NOT BE ACCURATE **
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DETAILED LTC COPAY TEST INCOME INFORMATION COULD NOT BE CONVERTED FOR THE
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FOLLOWING RELATIONS ASSOCIATED WITH THIS LTC COPAY TEST:
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THE LTC COPAY TEST WOULD HAVE TO BE EDITED.
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TYPE OF BENEFIT-ENROLLMENT
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APPLICANT OTHER NAME
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CHILD(N)
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Sp.
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QUESTION
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VistA :
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APPLICANT SOCIAL SECURITY NUMBER
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EAS(
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APPLICANT DATE OF BIRTH
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1010EZ data for
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was not filed to
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of File #
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A new record for
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could not be created in
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because Field #
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produced an error:
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APPLICANT SEX
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MEDICARE PART A EFFECTIVE DATE
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PART A
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MEDICARE PART B EFFECTIVE DATE
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PART B
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MEDICARE CLAIM NUMBER
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SIGNEE ON MEDICARE CARD
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APPLICANT INSURANCE COMPANY
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APPLICANT INSURANCE GROUP CODE
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APPLICANT INSURANCE POLICY HOLDER
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APPLICANT INSURANCE POLICY NUMBER
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SPOUSE INSURANCE COMPANY
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SPOUSE INSURANCE GROUP CODE
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SPOUSE INSURANCE POLICY HOLDER
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SPOUSE INSURANCE POLICY NUMBER
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New Patient record added by ELECTRONIC 10-10EZ.
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Applicant Data
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Application #:
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Received:
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Veteran Type:
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Enter Applicant data as prompted --
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NEW PT. FROM ELECTRONIC 10-10EZ -- IN PROCESS
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Sorry... cannot link to selected Patient.
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Application #
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is already linked to this Patient,
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and is still in-process.
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One moment please...
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Preparing for data comparison to VistA Patient database...
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EAS EZ 1010EZ INITIAL SCREEN
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Another user is processing that Application... try later.
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EAS EZ 1010EZ REVIEW1
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EAS EZ 1010EZ REVIEW2
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EAS EZ 1010EZ REVIEW3
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EAS EZ 1010EZ REVIEW4
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EAS EZ 1010EZ REVIEW5
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EAS EZ 1010EZ REVIEW6
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IN REVIEW
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PRINTED,PENDING SIG.
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Still filing...
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Application #:
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Applicant:
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Date Rec'd:
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Web ID #:
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Vet Sending Signed Form?:
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DATA ITEM
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Appointment Requested:
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Services Requested:
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Comments:
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Only two actions require a list line number indentifier --
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AF Accept Field
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AF=n
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to act on the field shown in line #n.
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UF Update Field
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UF=n
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All other actions act on the Application as a whole,
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so a line number is not used.
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Actions
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Verify Signature
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File 10-10EZ
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Inactivate
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can be used only once per Application.
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Allowed actions for NEW Applications are:
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Allowed actions for IN REVIEW Applications are:
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Allowed actions for PENDING SIGNATURE Applications are:
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Allowed actions for SIGNED Applications are:
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Allowed actions for FILED Applications are:
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There are no allowed actions for an INACTIVATED Application.
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LZ Link to Patient File
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The veteran associated with a NEW Application must be 'linked' to
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the VistA Patient database.
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VistA Patient Lookup function is employed to match the applicant
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to an existing Patient OR to establish a new Patient record.
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AF Accept Field
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The 10-10 EZ data element on line #n is 'accepted' for later filing
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into the VistA Patient database.
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Using this action on a previously 'accepted' data element,
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removes the 'accepted' indicator.
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AZ Accept All
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All 10-10 EZ data element are 'accepted' for later filing into
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CZ Clear All
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The 'accepted' indicator is removed from any fields previously
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RZ Reset to New
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The Application is returned to the 'New' processing status.
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It can be re-matched to the VistA database.
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IZ Inactivate
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Once the Application is inactivated, it will no longer be available
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for processing.
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Use this action only if the Application is deemed invalid or is being
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replaced by a new Application.
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PZ Print 10-10EZ
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Once the 10-10EZ is Printed, actions of Accept Field, Accept All,
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Clear All, and Update Field can no longer be used.
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The 10-10EZ form is printed using all 'accepted' data.
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VistA Patient data is used for any fields not 'accepted'.
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Printing must be queued to a valid print device.
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VZ Verify Signature
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The user verifies that the Applicant's signature appears on a
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UF Update Field
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The 10-10 EZ data element on line #n can be overwritten by the user for
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later filing into VistA.
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This action should be used to enter the Applicant's hand-written
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changes to the signed 10-10EZ.
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FZ File 10-10EZ
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All 'accepted' data elements on the 10-10EZ are filed to the
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VistA Patient database.
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Use this action with caution -- 10-10EZ data elements will overwrite
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any existing data in Vista.
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10-10EZ Application Processing --
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Select Applications to View
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PRINTED, PENDING SIG.
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Application Status:
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Please wait while processing...
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Vet
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Applications not yet filed to the Patient database.
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Select an Application to view.
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No Applications meet the selection criteria.
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Application being processed by another user.
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Try again late.....
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VALM STACK
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not allowed for this
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Do not select a slave device for output.
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This output requires a 132 column output printer.
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1010EZ PRINT
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The applicant has not been linked to the PATIENT File, #2
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This application has not been reviewed
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This application has already been closed, thE VA10-10EZ cannot be printed
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The VA10-10EZ for
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WEB submission ID:
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could not be printed for the following reason(s):
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OMB APPROVED NO. 2900-0091 / Est. Burden Avg. 20 min.
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APPLICATION FOR HEALTH BENEFITS
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APPLICATION FOR HEALTH BENEFITS, Continued
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AUTOMATED VA FORM 10-10EZ APR 1998
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1A. Type of Benefits Applied For:
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1B. If Applying For Health Services, Which VA Medical Center or Outpatient Clinic Do You Prefer
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|3. Other Names Used
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5. Social Security Number
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|6. Claim Number
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|7. Date of Birth
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9A. Current Mailing Address
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|10. Home Telephone Number
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|11. Work Telephone Number
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12. Current Marital Status:
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13A. Last Branch of Service
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|13B. Last Entry Date
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|13C.Last Discharge Date
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|13D. Discharge Type
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|13E. Military Service Number
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14. Answer Yes or No for the Following Questions
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Are You a Purple Heart Award Recipient
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Are You a Former Prisoner of War
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Do You Have a Military Dental Injury
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Do You Have a VA Service Connected Rating
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Do You Have a Spinal Cord Injury
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If Yes, What is Your Rated Percentage
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Are You Eligible for MEDICAID
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Are You Receiving a VA Pension:
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Are You Enrolled in MEDICARE Hospital Insurance Part A
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Are You Retired From The Military:
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Was Your Retirement The Result Of a Disability:
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Were You Regularly Retired (20+yrs.)
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Were You Exposed To Toxins In The Gulf War
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MEDICARE Claim Number
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Were You Exposed To Agent Orange
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Name Exactly As It Appears On Your MEDICARE Card
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Were You Exposed to Radiation
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15A. Veteran's Employment Status
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| 15B. Company Name, Address, Telephone
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Date of Retirement:
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(If employed or retired, complete 15B)
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16A. Spouse's Employment Status
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| 16B. Company Name, Address, Telephone
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(If employed or retired, complete 16B)
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17. Does The Veteran Have Health Insurance
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|18. Does The Spouse Have Health Insurance
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(Other Than Medicare)
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| (Other Than Medicare)
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17A. Veteran's Health Insurance Co.
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|18A. Spouse's Health Insurance Co.
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17B. Name of Policy Holder
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|18B. Name of Policy Holder
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17C. Policy Number
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|17D. Group Code
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|18C. Policy Number
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|18D. Group Code
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19A. Name, Address and Relationship Of Next of Kin
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|19B. Home Telephone
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|19C. Work Telephone
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20A. Name, Adress and Relationship Of Emergency Contact
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|20B. Home Telephone
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|20C. Work Telephone
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21. I DESIGNATE THE FOLLOWING INDIVIDUAL TO RECEIVE POSSESSION OF ALL MY PERSONAL PROPERTY LEFT ON PREMISES UNDER VA CONTROL AFTER
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MY DEPARTURE OR AT THE TIME OF MY DEATH. (This does not constitute a will or transfer of title.)
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22A. Is Need For Care Due To On The Job Injury
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|22B. Is Need For Care Due To Accident
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SECTION II - FINANCIAL ASSESSMENT
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IIA - DEPENDENT INFORMATION
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3. Spouse's Social Security Number
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|4. Spouse's Date Of Birth
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|5. Child's Date Of Birth
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|7. Child's Social Security Number
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8. Spouse's Telephone Number
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|9. Child's Relationship To You
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10. Date of Marriage
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|11. Date Child Became Your Dependent
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12. If Your Spouse or Dependent Child Did Not Live With You Last
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|13. Expenses Paid By YOUR Dependent Child for College, Vocational
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Year, Enter the Amount you Contributed To Their Support
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|Rehabilitation or Training (tuition, books, materials, etc.)
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Spouse $
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Child $
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#################### #################### ####################
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#################### #################### ####################
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#################### #################### ####################
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#################### #################### ####################
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#################### #################### ####################
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