308 lines
11 KiB
Plaintext
308 lines
11 KiB
Plaintext
English French Notes Complete/Exclude
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Weapons Total # :
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Firearms :
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Knives/Hatchets/Clubs :
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Explosives :
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Other :
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DISTURBANCES Total # :
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Demonstrations :
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Employee Threat :
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Smoking Violation :
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Unauthorized Photograph :
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MANSLAUGHTER/MURDER Total # :
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Manslaughter/Murder/Negligent :
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Manslaughter/Murder/Non-Neg. :
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NON-CRIMINAL INVESTIGATIONS Total # :
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Government Veh. Accident :
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Assist Law Officer :
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Alarm Response :
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Information Only :
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OTHER OFFENSES Total # :
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Arson :
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Arson $ Damage :
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Possession of Stolen Property :
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Receive/Sell Stolen Property :
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Suicide :
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Suicide Attempt :
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RAPES Total # :
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Attempted Rape :
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Forcible Rape :
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ROBBERY Total # :
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STOPS & ARRESTS Total # :
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Stops for Questioning :
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Package Stops :
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Non-Package Stops :
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THEFTS Total # :
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Coin-Operated Machines :
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Total $ Loss :
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Total $ Recovery :
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Actual Drug Thefts :
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Controlled Substance :
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Non-Controlled Substance :
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Attempted Drug Thefts :
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Total Drug Thefts :
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Total $ Recovered :
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Government Property :
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Personal Property :
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Motor Vehicles :
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Government Motor Vehicle :
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Gov't Vehicles Recovered :
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Private Motor Vehicle :
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Private Veh's Recovered :
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VICE SOLICITING Total # :
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Forgery :
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Gambling :
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Sexual Misconduct :
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VIOLATION CHARGES Total # :
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USDC Notice Total # :
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The report will be forwarded to the national database. You may now enter
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any additional people you would like to forward this report to.
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XXX@Q-VAP.VA.GOV
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...Forwarded to National Database.
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VICE SOLICITING Total # :
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Is this a courtesy or USDC violation
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Enter C for COURTESY or V for USDC violation
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The program is now exiting!
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Do you want to add a new violation
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DATE/TIME OF OFFENSE
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Enter the date and time of the offense. Future dates not allowed.
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Court Date must be after the Date/Time of Offense!
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NO EXISTING VIOLATIONS FOR
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EXISTING VIOLATIONS FOR
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OFFENSE CHARGED
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Data Validation in progress
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No Date/Time Received.
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No Date/Time of Offense.
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No Investigating Officer.
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No Classification Code.
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No Type for this Classification Code.
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No Sub-Type for this Type.
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This report must have the above before it can be completed.
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Report Completed.
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Select Vehicle Registration:
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VIOLATION #:
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PRINT USDC VIOLATION NOTICE
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OFFENSE CHARGED:
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OFFENSE DESCRIPTION:
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OFFENDER:
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RECORD DOESN'T EXIST.
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DRIVER'S LICENSE #:
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TAG # & STATE:
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VEHICLE COLOR:
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YEAR:
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COURT DATE:
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* * * VIOLATION NOTICE * * *
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* * * COURTESY VIOLATION NOTICE * * *
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Enter the Decal # (ex. 9999)
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NO MATCH FOUND.
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Do you want to add this decal #
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DECAL COLOR:
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VEHICLE MAKE:
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ASSIGNED PARKING SPACE:
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CAR POOL MEMBER:
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READY TO UPDATE
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Another user is editing this record!
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This decal # is already in the Police Registration Log.
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Do you want to edit this registration
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Select OFFICER
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This officer is not a current police officer.
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WORKLOAD REPORT
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ALL OFFICERS
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Checking SOUNDEX for matches.
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No matches found.
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Do you still want to add this entry: NO//
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NnYy^?
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Answer NO to stop the addition of
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as a new master name index person.
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Answer YES to add, a '^' will be taken as a NO.
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Print 7079's for:
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There are no 7079's to be printed!
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Want only those that have not yet been printed
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ID Card Number:
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(1) Veterans Name
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|(2) ID Number | Period of Validity
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|DATE OF ISSUE
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| CONDITIONS FOR WHICH SERVICES ARE REQUESTED (DESCRIPTION OF DISABILITY)
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Name and Address of Fee Participant
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AUTHORIZATION #:
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AUTHORIZATION REMARKS
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(5) STATE CODE | (6) COUNTY CODE | (7) TYPE OF | (8) YEAR OF BIRTH | (9) WAR | (10) PURPOSE |
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STATION OF JURISDICTION
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Veterans Administration
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SHORT TERM - 1
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HOME NURSING - 2
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ID CARD STATUS - 3
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| APPROVED BY (Name and Title)
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TELEPHONE:
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Information On Veterans Administration Program
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Acceptance of this request to render the prescribed services will constitute an agreement which is subject
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to the following:
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I. SERVICES. If services are not initiated, please return this document to the Station of Jurisdiction with a brief
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explanation. Unless approved by the VA, services are limited in type and extent to those shown.
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II. PERIOD OF VALIDITY. Service must be performed within the period of validity indicated.
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If a longer time is needed, please request an extension.
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III. REPORTS. Clinical reports are required when an examination only has been requested. Please
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submit reports promptly to the Station Of Jurisdiction.
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IV. STATEMENT OF ACCOUNTS. Submit a Statement of Account in your usual manner. Your statement must
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include: (1) Patient's Name; (2) Identification NO.; (3) Treatment (CPT) and Dates Rendered; and (4) Fees.
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V. FEES. Fees claimed may not exceed those made to the general public for like services.
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VI. PAYMENT. Payment by the VA for services rendered and approved is payment in full.
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VII. HOSPITALIZATION. When a need for hospital care is indicated, please call the Station of Jurisdiction
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for assistance in admitting the veteran to a VA hospital.
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VIII. INQUIRIES. Additional information when required may be obtained by contacting the Station Of Jurisdiction.
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VA Form 10-7079
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ELIGIBILITY HAS NOT BEEN DETERMINED NOR PENDING, CANNOT ENTER AN AUTHORIZATION.
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VETERAN HAS A DISHONORABLE DISCHARGE,
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ONLY ELIGIBLE FOR AGENT ORANGE EXAM.
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NOT ELIGIBLE FOR BENEFITS.
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Want to Print 7079 for this patient now
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Is this vendor information correct
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FBAA ESTABLISH VENDOR
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You must contact a vendorizing clerk or supervisor to update this record!
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Vendor flagged for updating!
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Are you sure you want to update this Vendor in the FMS and Central Fee vendor files
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Will NOT be Updated
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This option should only be used to update the FMS and Central
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Fee vendor files in Austin with the appropriate information.
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(NOTE: The vendor may not exist in the FMS vendor file,
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or may exist, but the information in the FMS vendor
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file does not reflect accurate information.)
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Use of this option should update the FMS system to reflect
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what is currently in the DHCP system. Information at all
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other VA Medical Centers using this vendor will also be updated.
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Sure you want to DELETE this batch
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Batch Deleted.
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Obligation Number:
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Do you want to change the Obligation Number
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Select Obligation Number:
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DUZ and DUZ(0) must be defined as a valid user to run the batch purge.
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You must have programmer access (DUZ(0)='@') before running the batch purge.
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There are no batches finalized !!
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This option is used to purge Fee Basis batch numbers for a time frame in the past. Do you want to continue
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if you wish to proceed with Fee Basis batch number purging!
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Purge batch #'s PRIOR to date :
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*** BEGIN FEE BASIS BATCH NUMBER PURGE ***
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There are no batch numbers to purge for this time frame !!
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This option has purged
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batch numbers
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finalized prior to
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*** FEE BASIS BATCH NUMBER PURGE FINISHED ***
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Unknown User
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FBAA BATCH PURGE
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Do you want to print ALL Fee Basis Batch Status':
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CLERK CLOSED
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SUPERVISOR CLOSED
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FORWARDED TO PRICER
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ASSIGNED PRICE
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REVIEWED AFTER PRICER
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Select STATUS to print
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Do you want to select another STATUS:
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FBSTAT(
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MEDICAL & STAT PAYMENTS
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HOMETOWN PHARMACY PAYMENTS
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TRAVEL PAYMENTS
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CH/CNH
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STATUS OF BATCHES
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BATCH #
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BATCH TYPE
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DATE OPENED
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No payments in Batch yet!
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No Payments in Batch yet!
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Want to review batch
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If you want a detail list of each payment line, answer
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otherwise press Return key
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Do you still want to close Batch
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Batch Closed
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('*' Reimbursement to Patient '+' Cancellation Activity)
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('#' Voided Payment)
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Batch #
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Voucher Date
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Vendor Name
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Vendor ID
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Invoice #
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Date Rec'd.
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SVC DATE
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CPT-MOD
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SERVICE PROVIDED
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FPPS CLAIM
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FPPS LINE
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ADJ CODE
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ADJ AMOUNT
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RX DATE
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RX #
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'+' Represents Cancellation Activity
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Travel Amount
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Invoice #:
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FPPS Claim ID:
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FPPS Line:
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('*' Reimbursement to Veteran '+' Cancellation Activity)
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Batch Number
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Dt Inv Rec'd
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FR DATE
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TO DATE CLAIMED PAID
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Dx:
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Proc:
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Date Paid:
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>>>Amount paid altered to $
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on the Fee Payment Voucher document.<<<
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>>>Check cancelled on:
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Check WILL be replaced.
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Check WILL be re-issued.
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Check WILL NOT be replaced.
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Patient has never been assigned ID Card!
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Current ID Card:
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Date Issued:
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No previous ID Cards!
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Does not currently have ID Card!
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Date/Time Changed
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Old Card #
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Person Who Changed
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Reason For Change
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There are no Invoices Pending completion!
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Fee Site Parameters must be Initialized!
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Invoice is Complete
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Totals: $
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Vendor:
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Vendor ID:
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Patient ID:
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FPPS Line Item:
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Drug Name
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Amt Claimed
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Generic Drug Substituted:
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Pharmacy Remarks:
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Hit Return to accept default dispensing fee or enter a dollar amount between .01 and 20
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**Payment is for emergency treatment under 38 U.S.C. 1725.
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Amount Paid cannot be greater than the Amount Claimed
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This option is restricted to holders of the 'FBAASUPERVISOR' security key.
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The last user to enter/edit this Authorization was
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FPPS CLAIM ID:
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Invoice:
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Service selected for that date already in system.
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Do you want to add another service for the SAME DATE
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You must use the 'EDIT PAYMENT' option to edit the service previously
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entered for that date.
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Want to edit it
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Warning, you can only enter
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more line(s)!
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This Batch already has the maximum number of Payments!
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Will any line items in this invoice be for contracted services
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Answering no indicates interest will not be paid for any line items.
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Patient:
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No Address information for this patient!
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Patient's Permanent address:
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Address Line
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Zip:
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County
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Want to edit Permanent Address data
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Payment is for a contracted service so fee schedule does not apply.
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However, f
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ee schedule amount is $
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from the
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Unable to determine a FEE schedule amount.
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Therefore, fee schedule amount reduced to $
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#################### #################### ####################
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#################### #################### ####################
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#################### #################### ####################
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#################### #################### ####################
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#################### #################### ####################
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