308 lines
14 KiB
Plaintext
308 lines
14 KiB
Plaintext
English French Notes Complete/Exclude
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14. Was Child Permanently And Totally Disabled Before
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|15. If Child is Between 18 and 23 Years Of Age, Did Child
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The Age Of 18?
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| Attend School Last Calendar Year?
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IIB - FINANCIAL DISCLOSURE
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You are not required to provide the financial information in this Section. However, current law may require VA to consider your
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household financial situation to determine your eligibility for enrollment and/or cost-free care of your nonservice-connected
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(NSC) conditions. If you are 0% SC noncompensable or NSC (and are not an Ex-POW, WWI veteran or VA pensioner) and your
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annual household income (or combined income net worth) exceeds the established threshold, you must agree to pay VA co-payments
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for care of your NSC conditions to be eligible for enrollment. See Section III - Consent and Signature
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YES, I WILL PROVIDE SPECIFIC INCOME AND/OR ASSET INFORMATION TO HAVE ELIGIBILITY FOR CARE DETERMINED. Complete all
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sections below that apply to you with last calendar year's information. Sign and date the application.
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NO, I DO NOT WISH TO PROVIDE MY DETAILED FINANCIAL INFORMATION. I understand I will be assigned the appropriate enrollment
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priority based on nondisclosure of my financial information. By checking NO and signing below, I am agreeing to pay the
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applicable VA co-payment. Sign and date the application.
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IIC - PREVIOUS CALENDAR YEAR GROSS ANNUAL INCOME OF VETERAN, SPOUSE AND DEPENDENT CHILDREN
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1. What Was Your Gross Annual Income From Employment (wages, bonuses,
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tips, etc), As Well as Income From Your Farm, Ranch, Property or Business
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2. List Other Income Amounts (Social Security, compensation, pension,
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interest, dividends) Exclude Welfare.
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3. Was Income From Your Farm, Ranch, Property or Business (if yes, refer to page 2, Section IIC of the instructions.)
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IID - DEDUCTIBLE EXPENSES
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1. Non-Reimbursed Medical Expenses Paid By You or Your Spouse (payments for doctors, dentists, drugs,
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Medicare, health insurance, hospital and nursing home)
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2. Amount You Paid Last Calendar Year For Funeral And Burial Expenses For Deceased Spouse or Dependent
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Child (also enter spouse or child's information in Section IIA)
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3. Amount You Paid Last Calendar Year For YOUR College or Vocational Educational Expenses (tutition, books,
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fees, materials, etc.) Do Not List Your Dependent's Educational Expenses.
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IIE - NET WORTH
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1. Cash, Amount In Bank Accounts (checking and savings accounts, certificates of deposit,
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individual retirement accounts, etc.)
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2. Market Value Of Land And Buildings MINUS Mortgages And Liens. Do NOT COUNT YOUR
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PRIMARY HOME. Include value of farm, ranch, or business assets.
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3. Stocks And Bonds AND Value Of Other Property or Assets (art, rare coins, etc.) MINUS
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The Amount You Owe On These Items. Exclude household effects and family vehicles.
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SECTION III
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CONSENT TO RELEASE INFORMATION
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my medical records (including information relating to the diagnosis, treatment of other therapy for the conditions of
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substance abuse, alcoholism or alcohol abuse, sickle cell anemia, or testing for or infection with the human immunodeficiency
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virus) to the contractor of any health plan contract under which I am apparently eligible for medical care or payment of the
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expense of care or to any other party against whom liability is asserted. I understand that I may revoke this authorization
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at any time, except to the extent that action has already been taken in reliance on it. Without my express revocation, this
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consent will automatically expire when all action arising from VA's claim for reimbursement for my medical care has been
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completed. I authorize payment of medical benefits to VA for any services for which payment is accepted.
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SOCIAL SECURITY NUMBER
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| DATE OF BIRTH
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SIGNATURE OF PATIENT
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III - CONSENT AND SIGNATURE
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ALL APPLICANTS MUST SIGN AND DATE THE APPLICATION FOR HEALTH BENEFITS
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clearance requirements of section 3507 of the Paperwork Reduction Act of 1995. We may not conduct or sponsor, and you are
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not required to respond to, a collection of information unless it displays a valid OMB number. We anticipate that the
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time expended by all individuals who must complete this form will average 20 minutes. This includes the time it will take
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to read instructions, gather the necessary facts and fill out the form.
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Privacy Act Information: The VA is asking you to provide the information on this form under Title 38, United States Code,
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sections 1710, 1712, and 1722 in order for VA to determine your eligibility for medical benefits. The information you supply
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may be verified through a computer-matching program. VA may disclose the information that you put on the form as permitted by
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law. VA may make a
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disclosure for: civil or criminal law enforcement, congressional communications,
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epidemiological or research studies, the collection of money owed to the United States, litigation in which the United States
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is a party or has interest, the administration of VA programs and delivery of VA benefits, verification of identity and status,
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and personnel administration. You do not have to provide the information to VA, but if you don't, we will be unable to
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process your request and serve your medical needs. Failure to furnish the information will not have any affect on any other
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benefits to which you may be entitled. If you give VA your Social Security Number, VA will use it to administer your VA
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benefits, to identify veterans and persons claiming or receiving VA benefits and their records, and for other purposes
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authorized or required by law.
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CO-PAYMENT NOTICE: If you are a 0% service-connected noncompensable or a nonservice-connected veteran (and are not an
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Ex-POW, WWI veteran or VA pensioner) AND your household income (or combined income and net worth) exceeds the established
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threshold, you may be eligible for enrollment only if you agree to pay VA co-payments for treatment of your NSC conditions.
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By signing this application you are agreeing to pay the applicable VA co-payment if required by law.
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I CERTIFY THE FOREGOING STATEMENT(S) ARE TRUE AND CORRECT TO THE BEST OF MY KNOWLEDGE AND ABILITY.
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SIGN HERE
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HEALTH SERVICES
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10-10EZ Application Quick Lookup --
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At the prompt, you may enter any one of the following:
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(1) Application ID
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(2) Web Submission ID
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Hyphens must appear just as received from
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the On-Line 1010-EZ application.
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(3) Applicant Name
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No space between last and first name.
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(4) Applicant SSN
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Must be entered as nnn-nn-nnnn.
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App #:
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Web ID:
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Date Rec'd:
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Applicant:
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Vet Type:
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Vet new to Vista?:
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Financial Disclosure:
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Expect copy from vet?:
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Review start date:
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Print date:
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Sign date:
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File date:
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Inactivate date:
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Appt. Requested:
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e-mail Address:
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Comments --
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NEXT-OF-KIN
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LAST NAME
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FIRST NAME
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MIDDLE NAME
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SUFFIX NAME
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AMERICAN SAMOA
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DISTRICT OF COLUMBIA
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FEDERATED STATES OF MICRONESIA
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MARSHALL ISLANDS
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NORTHERN MARIANA ISLANDS
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PALAU (TRUST TERRITORY)
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PUERTO RICO
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VIRGIN ISLANDS
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APPLICANT STATE
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WORK PHONE AREA CODE
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WORK PHONE NUMBER
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WORK PHONE EXTENSION
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HOME PHONE AREA CODE
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HOME PHONE NUMBER
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EMPLOYER PHONE AREA CODE
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EMPLOYER PHONE NUMBER
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EMPLOYER PHONE EXTENSION
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WIDOW/WIDOWER
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UNKNOWN/NO PREFERENCE
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SC 50-100%
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SC <50%
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SC 0%
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PURPLE HEART
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MIL. RETIREE
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SOCIAL SECURITY NUMBER
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DATE OF BIRTH
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'Accept Field'
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Printed
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Signed
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Filed
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Inactivated
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Sorry, that data element cannot be 'Accepted' for 'Filing'.
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After filing this Application to VistA, use Register a Patient
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or Patient Enrollment to enter/update data as needed.
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Sorry, that data element must be 'Accepted' for this Applicant.
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After filing this Application to VistA, the Registration options
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can be used to modify data as needed.
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After filing this Application to VistA, Integrated Billing users
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can modify the data using the 'Process Insurance Buffer' option.
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Sorry, that data element has been Updated and must be 'Accepted'
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for this Applicant.
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'Accept All'
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'Clear All'
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Sorry, the 'Clear All' action cannot be used for this new patient.
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It is recommended that all data elements be 'Accepted' for 'Filing'.
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After filing the Application to VistA, the Registration options
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can be used to modify data.
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'Reset to New'
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Application has been Reset to New...
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Unreviewed
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'Verify Signature'
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Previously Signed
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Applicant signature is verified...
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Unsigned
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Previously Filed
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Previously Inactivated
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Application has been closed/inactivated...
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Filing 10-10EZ Data (Appl. #
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) to VistA
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10-10EZ data is being filed as a background job.
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Task #:
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'Print Data'
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Data Print queued to background...
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'Update Field'
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Sorry...the selected data element cannot be 'Updated'.
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No punctuation is allowed other than
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in a hyphenated name.
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No punctuation or numerics are allowed.
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AREA CODE
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Use format nnn-nnnn. Example: 222-1234
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Use up to 5 digits; no other characters. Example: 12345
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Use format nnn-nnn-nnn. Example: 222-33-4444
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Sorry... that SSN is already used by another person
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in the INCOME PERSON File (#408.13). Try again.
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SID
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VISTA AUTOMATION
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ADDITIONAL CHILD
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Services Request
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Submit ID
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Email Address
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Version #
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Veteran To Mail
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Provide
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Details
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Appointment Request
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APPLICANT LAST NAME
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APPLICANT FIRST NAME
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APPLICANT MIDDLE NAME
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APPLICANT SUFFIX NAME
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RATED PERCENTAGE
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RETIRED FROM MILITARY
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Receipt Confirmation for:
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Sent from:
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Site msg #:
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1010EZ CONFIRMATION for SID
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GMT Threshold Lookup by Zip Code or City
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ZIP Code
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Zip Code is invalid; there is no GMT Threshold associated with this value.
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Enter the ZIP code [5 - 12 characters] that you wish to select.
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GMT Thresholds not found for entered ZIP code.
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GMT Threshold is not available for entered ZIP code.
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County Name:
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State:
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FIPS Code
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# in Household
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GMT Threshold
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EAS MTOVERRIDE
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Means Test Alert
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A Means Test is required or needs to be completed.
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Please perform MEANS TEST or instruct patient
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to report for Means Test interview.
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>> A future appointment cannot be made at this time.
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>> Override Key in Effect.
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>> This action may not be completed at this time.
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>> Check-Out ONLY. Do NOT Check-In (CI) a walk-in appointment
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You will not be able to check-out the appt. if you do so.
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AUTOMATED MT LETTERS GENERATOR
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The prior processing date is not available. A default date
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will be used.
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Ok to continue?
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Select new start date:
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>> The Means Test Letter search has been run for today.
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Auto MT Letters: This process is already running,
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This process is already running, please try again later
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Auto-Letters Search completed:
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>> Processing date
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in progress <<
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Automated Means Test Letter Generator Statistics
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Beginning Processing Date:
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Ending Processing Date:
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-day Letters:
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Day Letter Totals:
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AUTO MT LETTER RESULTS -
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AUTOMATED MT LETTERS
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Filter letters by Preferred Facility?
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Enter 'YES' to limit letters to a specific Facility or 'NO' to print all letters
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No valid processing date could be found for
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-day letters for
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Please select another date.
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To re-print
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the Search/Processing date of
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Please note: ALL
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-day letters for this processing date will print
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Enter 'YES' to use the
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date. Enter 'NO' to select a different date.
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Do you wish to use this date?
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Select the date for the letters you wish to re-print.
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Enter re-print date:
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Select letter type
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Select the type of letter to re-print
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EAS MT LETTERS REPRINT
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Reprint canceled
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Letters queued, [
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...Gathering letters to re-print...
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>> No letters found to reprint for these parameters.
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Select Patient Letter status entry to reprint
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The Prohibit flag is set for this patient
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Patient is deceased
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Select Processing Date:
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Select the letter processing date for this patient
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A Means Test has already been returned by this patient
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Patient's Means Test is no longer required
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There are no letters to re-print for this patient
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Select letter type to re-print
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EAS MT RERUN SINGLE LETTER
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Available Processing Dates:
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ERROUT(1)
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Unable to generate entry in EAS MT PATIENT STATUS File, #713.1
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NO LONGER REQUIRED
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The following issues were reported by the Means Test Letter Search Process:
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MT LETTERS SEARCH ISSUES -
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Select the type of letter to print
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EAS MT LETTERS PRINT JOB
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Letters canceled!
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Letters queued! [
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...Gathering letters to print...Please wait
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...Printing letters...
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Letters to print:
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Letters where the print date has not reached:
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The following letters were found but not printed for the following reasons:
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Incomplete/Bad Addr :
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Deceased :
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MT Changed:
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Prohibit flag set:
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Not a User Enrollee:
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Not a User Enrollee of this facility:
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Total Letters Processed:
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(MT not returned)
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Print Letter Results
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STOPPED BY USER
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4///YES;5///TODAY;7///MT 'OWNED' BY ANOTHER FACILITY;9///NO;12///NO;18///NO
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MEANS TEST ANNIVERSARY DATE:
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Dear
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Mr./Ms.
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VA Medical Center
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Enclosure
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TEST LETTER (DO NOT MAIL!)
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THIS IS A TEST LETTER STREET ADDRESS
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#################### #################### ####################
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#################### #################### ####################
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#################### #################### ####################
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#################### #################### ####################
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#################### #################### ####################
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