308 lines
14 KiB
Plaintext
308 lines
14 KiB
Plaintext
English French Notes Complete/Exclude
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Y - If you want to purge data.
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N - If you don't wish to purge data.
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Purge patients not seen since:
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SELECT A DATE IN THE PAST PLEASE!!
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I'm going to purge all patients from the INCONSISTENT DATA file who haven't been
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admitted or registered since
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Is this correct
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Y - To start the purge process.
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N - To QUIT.
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Generate a listing of inconsistent data elements by:
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CHOOSE OUTPUT METHOD OR ENTER '^' TO QUIT:
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The available choices are:
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Go To
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List by (N)ame or (T)erminal Digit:
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N - To generate listing in Alphabetical Order
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T - To generate listing in Terminal Digit Order.
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THIS OUTPUT REQUIRES 132 COLUMN OUTPUT
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INCONSISTENT ELEMENTS FOR PATIENTS WITH A
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Missing
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Last Day
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Home Phone #
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Soc Sec #
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ID'ed
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Edited by
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Inconsistent/Missing Data Elements
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TABLE OF INCONSISTENT/MISSING DATA ELEMENTS
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UNIDENTIFIED PATIENT #
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Do you want to delete the existing entries and rebuild the file
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Y - If you want to remove all existing entries from the INCONSISTENT DATA
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file and rebuild from scratch.
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N - If you just want to add newly identified inconsistencies to the
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existing file.
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Rebuild for patients seen since what date:
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I'm going to check all patients who were admitted or registered on or after
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[Within the Past
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DELETE all existing entries prior to rebuilding
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add any new inconsistent data elements to the existing file
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Y - If this is what you want to do.
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N - If you wish to STOP processing and reconsider this action.
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INCONSISTENT DATA^38.5P^^0
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' OPTION RUNNING FROM
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UNABLE TO RUN THIS OPTION AT CURRENT TIME!!
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Do you really want to update existing inconsistent entries
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Y - If you want me to run through all the entries currently filed in
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the INCONSISTENT DATA file and verify they're still inconsistent.
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N - If you wish to QUIT and rethink this action.
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This check can not be edited. It is automatically turned
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Temporary:
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POS:
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Claim #:
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Relig:
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Ethnicity:
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Primary Eligibility:
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PENDING REVERIFICATION
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Other Eligibilities:
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Confidential Address:
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From/To: NOT APPLICABLE
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From/To:
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COORDINATING MASTER OF RECORD:
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Scheduled Admit
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for treating specialty
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Currently enrolled in
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Future Appointments:
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See Scheduling options for additional appointments.
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* NO ACTION TAKEN *
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Press RETURN to CONTINUE:
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Catastrophically Disabled Review Date:
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Primary Elig. Code:
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Other Elig. Code(s):
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Service Connected: NO
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SC Percent:
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NOT A VETERAN
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Health Insurance:
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Medicaid Elig:
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Means Test Status: NOT IN MEANS TEST FILE
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Invalid pseudo SSN.
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Type 'P' for the valid one
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Pseudo SSN adjusted to match edited name value ==>
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VERIFY FIELDS
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Already used by patient '
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The SSN must not begin with 9.
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First three digits cannot be zeros.
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Note: This is a RR Retirement SSN.
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Note: This is a Test Patient SSN.
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Collateral of
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Must have same SSN to be collateral
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Has collateral
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be sure to change SSN
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The date of birth is too early for the selected category of beneficiary
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Make another selection or correct the date of birth.
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The date of birth is too late for the selected category of beneficiary.
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The patient's age is too young for the selected category of beneficiary.
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This service entry date would make the patient too young for service.
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DOB
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Previous service entry date is not on file
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This service entry date must be before than the first service entry date
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This service entry date must be less than the second service entry date
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The service separation date must be after the entry date
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This service separation date must be before the next service entry date
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The service separation date must be before the next service entry date
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**NOTE-Change(s) made in this session deleted the veteran's Combat Vet status!
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But I need a Start Date for this Temporary Address.
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But I need at least one line of a Temporary address.
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But I need a Start Date.
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But I need at least one active category.
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I need at least one line of Address.
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But I need to know where you were treated most recently.
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Patient is not a veteran. Can't enter rated disabilities
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SPOUSE'S
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DEPENDENT'S
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CHILD'S
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Incomplete Entry...Deleted
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No dependents to inactivate!
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Enter a number 1-
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to indicate the dependent you wish to inactivate:
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indicating the number of the dependent you wish to inactivate
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RELATIONSHIP:
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Entry incomplete...deleted
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Dependent has been inactivated as of
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Date
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no longer a dependent
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Enter the date this person was no longer a dependent of the veteran.
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This could include a date of death or the date a child turned 18 for
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children. For a spouse, this would be the date of divorce or date
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of death of the spouse. Date must be after the person became a
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dependent, but prior to 12/31/
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A person should only be inactivated if the individual was not a
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dependent at any time during the prior calendar year.
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A spouse should be inactivated if the spouse and veteran were not
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married as of 12/31/
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Warning: Data will be used if dependent was active at least one day in a
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year. Data will not be used if inactivation is prior to 1/1/
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or it
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is equal to the activation date.
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Do you wish to inactivate this dependent on the selected date?
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[Must edit through means test!!]
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EFFECTIVE DATE
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Please return to screen 8 and check the veteran's effective date.
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The effective date was created based on the veteran's date of birth.
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You might also want to check the date of birth for this veteran.
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This dependent is 18 years or older. To list this person as a dependent
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they have to be:
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1. An UNMARRIED child who is under the age of 18.
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2. Between the ages of 18 and 23 and attending school.
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3. An unmarried child over the age of 17 who became permanently
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incapable of self support before the age of 18.
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Use 'Expand Dependent' option to change effective date.
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Enter the date this person first became a dependent of the veteran.
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In the case of a spouse, this would be the date of marriage. For
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a parent or other dependent, this would be the date the dependent
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moved in. For a child, this would be the date of birth or date of
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Date must be before DEC 31,
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as dependents are collected for the
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prior calendar year only.
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Enter '^' to stop the display
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and edit
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of data, '^N' to jump to screen #N (see
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listing below), <RET> to continue on to the next available screen
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or enter
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the field group number(s) you wish to edit using commas and dashes as
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delimiters. Those groups enclosed in brackets
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are editable while those
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enclosed in arrows
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are not.
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Enter 'ALL' to edit all editable data
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elements on the screen.
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You may precede your selection with 'V' to denote veteran.
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DATA GROUPS ON SCREEN
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Press RETURN key
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to EXIT Screen
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TO EXIT
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Name, SSN, DOB^Alias Name & SSN (if applicable)^Remarks concerning this patient^Home Address, Phone & Work Phone^Temporary Address, Dates, Phone
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Confidential Address,Dates and Types
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Sex, POB, Parents, etc.^Dates/Locations of Previous Care^Race and Ethnicity
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Primary Next-of-Kin^Secondary Next-of-Kin^Primary Emergency Contact^Secondary Emergency Contact^Designee to receive personal effects
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Applicant Employer, Address^Spouses Employer, Address
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Unexpired Insurance Policies^Eligibile for Medicaid
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Service History^Prisoner of War^Combat^Vietnam Service^Agent Orange Exposure^IONizing Radiation Exposure^
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Lebanon Service^Grenada Service^Panama Service^Persian Gulf Service^Somalia Service^Environmental Contaminants Exposure^Military Retirement/Disability^Dental History^Yugoslavia Service^Purple Heart Recipient^
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Nose/Throat Radium Treatment
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Patient Type, SC Data, Claim Info^VA Monetary Benefits^POS, Eligibility Code(s)^SC Conditions relayed by applicant
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Spouse's Demographic Info^Dependents' Demographic Info
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Social Security^U.S. Civil Service^U.S. Railroad Retirement^Military Retirement^Unemployment^Other Retirement^Total Employment Income^Interest,Dividend,Annuity^Workers Comp or Black Lung^Other Income
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Ineligible Patient Information^Missing Patient Information
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Eligibility Verification^Monetary Benefits Verification^Service Record Verification^Rated Disabilities (VA)
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Four most recent admission episodes on file for this applicant are displayed
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in inverse order.
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Four most recent applications for care (registrations) are displayed in
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inverse order.
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Clinics in which actively enrolled^Pending (future) appointments
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Sponsor information is displayed for patients.
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Demographic^Confidential Address^Patient^Contact^Employment^Insurance^Service Record^Eligibility^Family Demographic^Income Screening^Missing/Ineligible^Eligibility Verification^
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Admission Info^Application Info^Appointment Info^Sponsor Demograhics
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Enter your division:
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Unable to update Purple Heart Data.
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Unable to update Purple Heart History.
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=ENTER new
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to EDIT,
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for screen N or
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to QUIT
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COPYING will move Family Demographic and Income Data into the next year...
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YOU HAVE ALREADY MODIFIED CURRENT YEAR DEPENDENT INFORMATION
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COPYING will OVERWRITE this modified dependent information
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with LAST year's data - ** Please review dependent data **
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...FAMILY DEMOGRAPHIC DATA COPIED
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...............INCOME DATA COPIED
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===> Record has been classified as sensitive.
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Your MAS PARAMETER file is not properly set up!
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LOCAL REGISTRATION QUESTIONS
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INVALID SCREEN NUMBER...VALID SCREENS ARE
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(To edit only veteran income, precede selection with 'V' [ex. 'V1-3']
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precede with 'S' to edit spouse
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precede with 'D' to edit dependents
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>>> Patient cannot be registered while there is still an open disposition.
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Patient: Eligibility, Demographic
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Emergency Contact and Military Service
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Marital
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Another user is editing, try later...
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Insurance
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HINQ Inquiry
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Consistency Checker
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At this time you may Register the patient if he or she is present and
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seeking care. Answer 'No' if this was a mail-in application.
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Would you like to Register the patient
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Exit Interview
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PRINT 10/10T
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DGRPT 10-10T REGISTRATION
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Patient Demographics
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Permanent Address:
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Emergency Contact
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NOK:
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Military Service
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Service Branch [Last]:
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Number [Last]:
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Purple Heart:
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Eligibility
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Patient Type:
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Primary Elig Code:
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Marital/Spouse
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Spouse's Name:
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Last Year's Estimated
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Covered by Health Insurance:
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Insurance Co. Subscriber ID Group Holder Effective Expires
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PRINT 10-10T
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- FROM REGISTRATION
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Reg Date/Time:
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AUTOMATED VA FORM 10-10T
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VA FORM 10-10T
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|2. Social Security Number
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|3. Date of Birth
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4A. Applicant's Mailing Street Address
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|4D. Zip Code
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|6. Home Telephone Number
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|7. Work Telephone Number
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8A. Emergency Contact
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|8C. Home Telephone Number
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|8D. Work Telephone Number
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8E. Mailing Address of Emergency Contact
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|9. Is Emergency Contact
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|Also Next of Kin
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10. Benefit Applying For:
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HOSPITAL/OUTPATIENT TREATMENT
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11. Applicant Status:
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A. Service Connected
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|B. Prisoner of War
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|C. Aid and Attendance
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|D. Military Disability Retired
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E. VA Pension
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|F. Primary Eligibility Code
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|G. Other Eligibility Code
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|H. Purple Heart Recipient
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12. Exposure To:
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|A. Agent Orange
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|C. Environmental Contaminants
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13. Medical Care Related To:
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14A. Do You Have Health Coverage
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|14B. Name of Health Insurance Carrier
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15. Branch of Service
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|16. Latest Service Number
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|17. Marital Status
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|18B. Spouse's Social Security Number
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18C. Year of Marriage
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|18D. Number of Dependents
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|19. Last Year's Estimated
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Taxable Income
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Consent To Release Information: I hereby authorize the Department of Veterans Affairs to disclose any such history, diagnostic and
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treatment information from my medical records (including information relating to the diagnosis, treatment or other therapy for the
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conditions of drug abuse, alcoholism or alcohol abuse, sickle cell anemia, or testing for or infection with the human
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immunodeficiency virus) to the carrier or contractor of any health plan contract under which I am apparently entitled to medical
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care or payment of the expense of care that is identified above, as considered necessary by VA representatives for the discharge
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of the legal or contractual obligations of the insurer or other party against whom liability is asserted. I understand that I
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may revoke this authorization at any time, except to the extent that action has already been taken in reliance on it. Without my
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express revocation, this consent will automatically expire when all action arising from VA's claim for reimbursement for my
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medical care has been completed.
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Co-payment Notice: If your household income exceeds the established threshold, you will be considered
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Discretionary
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Such veterans must pay a co-payment not to exceed the Medicare deductible, plus a per diem for hospital and nursing care.
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By signing this application, you are agreeing to pay the VA the applicable co-payment if you are determined to be a
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Signature of Applicant
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Public reporting burden for this collection of information is estimated to average 10 minutes per response, including the time for
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reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the
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#################### #################### ####################
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#################### #################### ####################
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#################### #################### ####################
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#################### #################### ####################
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#################### #################### ####################
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