AGMSP1 ; IHS/ASDS/EFG - PRINT PAGE 1 OF MSP FORM ;
;;7.1;PATIENT REGISTRATION;;AUG 25,2005
;
;I AG("MSPPRINT") EXISTS, MAP DATA FROM AUPNMSP TO THE FORM
;
EN ;EP
W !,"PART I",!
I '$D(AG("MSPPRINT")) D BLANK1
I $D(AG("MSPPRINT")) D MAP1
W !!!
W !,?50,"Continued on next page ==>"
W !,AGLINE("EQ")
W !,$P($G(^DIC(4,DUZ(2),0)),U),?73,"PAGE 1"
Q
BLANK1 ;THIS SECTION IS USED TO PRINT THE BLANK PAGE 1
W !,?2,"1. Are you receiving Black Lung (BL) Benefits ? ",!
W !,?5,"[ ] YES Date primary benefits begin: _______________"
W !,?14,"BL is primary only for claims related to BL"
W !,?5,"[ ] NO",!
W !,?2,"2. Are the services to be paid by a government program such as a research"
W !,?5,"grant ? ",!
W !,?5,"[ ] YES Government Program will pay primary benefits for these services.",!
W !,?5,"[ ] NO",!
W !,?2,"3. Has the Department of Veteran Affairs (DVA) authorized and agreed to pay"
W !,?5,"for care at this facility ? ",!
W !,?5,"[ ] YES: VA is primary for these services."
W !,?5,"[ ] NO",!
W !,?2,"4. Was the illness/injury due to a work related accident/condition ? ",!
W !,?5,"[ ] YES Date of injury/illness: _______________"
W !,?14,"Name and address of Workman's Compensation (WC) plan:",!
W !,?14,$E(AGLINE("_"),1,50),!
W !,?14,$E(AGLINE("_"),1,50),!
W !,?14,$E(AGLINE("_"),1,50),!
W !,?14,"Patient's policy or identification number: _______________"
W !,?14,"Name and address of your employer:",!
W !,?14,$E(AGLINE("_"),1,50),!
W !,?14,$E(AGLINE("_"),1,50),!
W !,?14,$E(AGLINE("_"),1,50),!
W !,?2,"WC is primary payer only for claims related to work-related injuries or"
W !?2,"illness. GO TO PART III.",!
W !?5,"[ ] NO - GO TO PART II",!
Q
MAP1 ;THIS SECTION IS USED TO PRINT THE PATIENT'S DATA ON THE FORM
W !,?2,"1. Are you receiving Black Lung (BL) Benefits ? ",!
I $P(MSPRES(9000037,AG("DA"),.06),U)="" D
. W !,?5,"[ ] YES Date primary benefits begin: _______________",!
. W !,?5,"[ ] NO",!
I $P(MSPRES(9000037,AG("DA"),.06),U)="NO" D
. W !,?5,"[ ] YES Date primary benefits begin: _______________",!
. W !,?5,"[X] NO",!
I $P(MSPRES(9000037,AG("DA"),.06),U)="YES" D
. W !,?5,"[X] YES Date primary benefits begin: "
. W $P(MSPRES(9000037,AG("DA"),.07),U)
. W !,?5,"[ ] NO",!
;
W !,?2,"2. Are the services to be paid by a government program such as a research"
W !,?5,"grant ? ",!
I $P(MSPRES(9000037,AG("DA"),.08),U)="YES" D
. W !,?5,"[X] YES Government Program will pay primary benefits for these services.",!
. W !,?5,"[ ] NO",!
I $P(MSPRES(9000037,AG("DA"),.08),U)="NO" D
. W !,?5,"[ ] YES Government Program will pay primary benefits for these services.",!
. W !,?5,"[X] NO",!
I $P(MSPRES(9000037,AG("DA"),.08),U)="" D
. W !,?5,"[ ] YES Government Program will pay primary benefits for these services.",!
. W !,?5,"[ ] NO",!
;
W !,?2,"3. Has the Department of Veteran Affairs (DVA) authorized and agreed to pay"
W !,?5,"for care at this facility ? ",!
I $P(MSPRES(9000037,AG("DA"),.09),U)="YES" D
. W !,?5,"[X] YES",!
. W !,?5,"[ ] NO",!
I $P(MSPRES(9000037,AG("DA"),.09),U)="NO" D
. W !,?5,"[ ] YES",!
. W !,?5,"[X] NO",!
I $P(MSPRES(9000037,AG("DA"),.09),U)="" D
. W !,?5,"[ ] YES",!
. W !,?5,"[ ] NO",!
;
W !,?2,"4. Was the illness/injury due to a work related accident/condition ? ",!
I $P(MSPRES(9000037,AG("DA"),.11),U)="NO"!($P(MSPRES(9000037,AG("DA"),.11),U)="") D
. W !,?5,"[ ] YES Date of injury/illness: _______________"
. W !!,?14,"Name and address of Workman's Compensation (WC) plan:",!
. W !,?14,$E(AGLINE("_"),1,50),!
. W !,?14,$E(AGLINE("_"),1,50),!
. W !,?14,$E(AGLINE("_"),1,50),!
. W !,?14,"Patient's policy or identification number: _______________"
. W !,?14,"Name and address of your employer:",!
. W !,?14,$E(AGLINE("_"),1,50),!
. W !,?14,$E(AGLINE("_"),1,50),!
. W !,?14,$E(AGLINE("_"),1,50),!
. I $P(MSPRES(9000037,AG("DA"),.11),U)="NO" W !,?5,"[X] NO - GO TO PART II"
. I $P(MSPRES(9000037,AG("DA"),.11),U)="" W !,?5,"[ ] NO - GO TO PART II"
I $P(MSPRES(9000037,AG("DA"),.11),U)="YES" D
. W !,?5,"[X] YES "
. I $P(MSPRES(9000037,AG("DA"),.12),U)'="" D
. . W "Date of injury/illness: ",$P(MSPRES(9000037,AG("DA"),.12),U)
. I $P(MSPRES(9000037,AG("DA"),.12),U)="" D
. . W "Date of injury/illness: _______________"
. W !,?14,"Name and address of Workman's Compensation (WC) plan:",!
. I $P(MSPRES(9000037,AG("DA"),.13),U)="" D
.. W !,?14,$E(AGLINE("_"),1,50),!
.. W !,?14,$E(AGLINE("_"),1,50),!
.. W !,?14,$E(AGLINE("_"),1,50),!
. I $P(MSPRES(9000037,AG("DA"),.13),U)'="" D
.. S AG("INSPTR")=$P($G(^AUPNMSP(AG("DA"),1)),U,8)
.. S AG("INSADDR")=$G(^AUTNINS(AG("INSPTR"),0))
.. W !,?14,$P(AG("INSADDR"),U),! ;INSURER NAME
.. W !,?14,$P(AG("INSADDR"),U,2),! ;INSURER STREET
.. W !,?14,$P(AG("INSADDR"),U,3) ;INSURER CITY
.. I $P(AG("INSADDR"),U,4)'="" D
... W ", ",$P($G(^DIC(5,$P(AG("INSADDR"),U,4),0)),U,2) ;INSURER STATE
.. W " ",$P(AG("INSADDR"),U,5),! ;INSURER ZIP CODE
. I $P(MSPRES(9000037,AG("DA"),.14),U)="" D
.. W !!,?14,"Patient's policy or identification number: _______________"
. I $P(MSPRES(9000037,AG("DA"),.14),U)'="" D
.. W !,?14,"Patient's policy or identification number: ",$P(MSPRES(9000037,AG("DA"),.14),U)
. I $P(MSPRES(9000037,AG("DA"),.15),U)="" D
.. W !,?14,"Name and address of your employer:",!
.. W !,?14,$E(AGLINE("_"),1,50),!
.. W !,?14,$E(AGLINE("_"),1,50),!
.. W !,?14,$E(AGLINE("_"),1,50),!
. I $P(MSPRES(9000037,AG("DA"),.15),U)'="" D
.. S AG("EMPPTR")=$P($G(^AUPNMSP(AG("DA"),1)),U,10)
.. I $G(AG("EMPPTR"))'="" D
... S AG("EMPADDR")=$G(^AUTNEMPL(AG("EMPPTR"),0))
... W !,?14,"Name and address of your employer:",!
... W !,?14,$P(AG("EMPADDR"),U),! ;EMPLOYER
... W !,?14,$P(AG("EMPADDR"),U,2),! ;EMPLOYER STREET
... W !,?14,$P(AG("EMPADDR"),U,3) ;EMPLOYER CITY
... W:$P(AG("EMPADDR"),U,4)'="" ", ",$P($G(^DIC(5,$P(AG("EMPADDR"),U,4),0)),U,2) ;EMPLOYER STATE
... W ", ",$P(AG("EMPADDR"),U,5),! ;EMPLOYER ZIP
.. I $G(AG("EMPPTR"))="" D
... W !,?14,$E(AGLINE("_"),1,50),!
... W !,?14,$E(AGLINE("_"),1,50),!
... W !,?14,$E(AGLINE("_"),1,50),!
. W !,?5,"[ ] NO - GO TO PART II",!
K AG("INSPTR"),AG("INSADDR"),AG("EMPPTR"),AG("EMPADDR")
Q
AGMSP1 ; IHS/ASDS/EFG - PRINT PAGE 1 OF MSP FORM ;
+1 ;;7.1;PATIENT REGISTRATION;;AUG 25,2005
+2 ;
+3 ;I AG("MSPPRINT") EXISTS, MAP DATA FROM AUPNMSP TO THE FORM
+4 ;
EN ;EP
+1 WRITE !,"PART I",!
+2 IF '$DATA(AG("MSPPRINT"))
DO BLANK1
+3 IF $DATA(AG("MSPPRINT"))
DO MAP1
+4 WRITE !!!
+5 WRITE !,?50,"Continued on next page ==>"
+6 WRITE !,AGLINE("EQ")
+7 WRITE !,$PIECE($GET(^DIC(4,DUZ(2),0)),U),?73,"PAGE 1"
+8 QUIT
BLANK1 ;THIS SECTION IS USED TO PRINT THE BLANK PAGE 1
+1 WRITE !,?2,"1. Are you receiving Black Lung (BL) Benefits ? ",!
+2 WRITE !,?5,"[ ] YES Date primary benefits begin: _______________"
+3 WRITE !,?14,"BL is primary only for claims related to BL"
+4 WRITE !,?5,"[ ] NO",!
+5 WRITE !,?2,"2. Are the services to be paid by a government program such as a research"
+6 WRITE !,?5,"grant ? ",!
+7 WRITE !,?5,"[ ] YES Government Program will pay primary benefits for these services.",!
+8 WRITE !,?5,"[ ] NO",!
+9 WRITE !,?2,"3. Has the Department of Veteran Affairs (DVA) authorized and agreed to pay"
+10 WRITE !,?5,"for care at this facility ? ",!
+11 WRITE !,?5,"[ ] YES: VA is primary for these services."
+12 WRITE !,?5,"[ ] NO",!
+13 WRITE !,?2,"4. Was the illness/injury due to a work related accident/condition ? ",!
+14 WRITE !,?5,"[ ] YES Date of injury/illness: _______________"
+15 WRITE !,?14,"Name and address of Workman's Compensation (WC) plan:",!
+16 WRITE !,?14,$EXTRACT(AGLINE("_"),1,50),!
+17 WRITE !,?14,$EXTRACT(AGLINE("_"),1,50),!
+18 WRITE !,?14,$EXTRACT(AGLINE("_"),1,50),!
+19 WRITE !,?14,"Patient's policy or identification number: _______________"
+20 WRITE !,?14,"Name and address of your employer:",!
+21 WRITE !,?14,$EXTRACT(AGLINE("_"),1,50),!
+22 WRITE !,?14,$EXTRACT(AGLINE("_"),1,50),!
+23 WRITE !,?14,$EXTRACT(AGLINE("_"),1,50),!
+24 WRITE !,?2,"WC is primary payer only for claims related to work-related injuries or"
+25 WRITE !?2,"illness. GO TO PART III.",!
+26 WRITE !?5,"[ ] NO - GO TO PART II",!
+27 QUIT
MAP1 ;THIS SECTION IS USED TO PRINT THE PATIENT'S DATA ON THE FORM
+1 WRITE !,?2,"1. Are you receiving Black Lung (BL) Benefits ? ",!
+2 IF $PIECE(MSPRES(9000037,AG("DA"),.06),U)=""
Begin DoDot:1
+3 WRITE !,?5,"[ ] YES Date primary benefits begin: _______________",!
+4 WRITE !,?5,"[ ] NO",!
End DoDot:1
+5 IF $PIECE(MSPRES(9000037,AG("DA"),.06),U)="NO"
Begin DoDot:1
+6 WRITE !,?5,"[ ] YES Date primary benefits begin: _______________",!
+7 WRITE !,?5,"[X] NO",!
End DoDot:1
+8 IF $PIECE(MSPRES(9000037,AG("DA"),.06),U)="YES"
Begin DoDot:1
+9 WRITE !,?5,"[X] YES Date primary benefits begin: "
+10 WRITE $PIECE(MSPRES(9000037,AG("DA"),.07),U)
+11 WRITE !,?5,"[ ] NO",!
End DoDot:1
+12 ;
+13 WRITE !,?2,"2. Are the services to be paid by a government program such as a research"
+14 WRITE !,?5,"grant ? ",!
+15 IF $PIECE(MSPRES(9000037,AG("DA"),.08),U)="YES"
Begin DoDot:1
+16 WRITE !,?5,"[X] YES Government Program will pay primary benefits for these services.",!
+17 WRITE !,?5,"[ ] NO",!
End DoDot:1
+18 IF $PIECE(MSPRES(9000037,AG("DA"),.08),U)="NO"
Begin DoDot:1
+19 WRITE !,?5,"[ ] YES Government Program will pay primary benefits for these services.",!
+20 WRITE !,?5,"[X] NO",!
End DoDot:1
+21 IF $PIECE(MSPRES(9000037,AG("DA"),.08),U)=""
Begin DoDot:1
+22 WRITE !,?5,"[ ] YES Government Program will pay primary benefits for these services.",!
+23 WRITE !,?5,"[ ] NO",!
End DoDot:1
+24 ;
+25 WRITE !,?2,"3. Has the Department of Veteran Affairs (DVA) authorized and agreed to pay"
+26 WRITE !,?5,"for care at this facility ? ",!
+27 IF $PIECE(MSPRES(9000037,AG("DA"),.09),U)="YES"
Begin DoDot:1
+28 WRITE !,?5,"[X] YES",!
+29 WRITE !,?5,"[ ] NO",!
End DoDot:1
+30 IF $PIECE(MSPRES(9000037,AG("DA"),.09),U)="NO"
Begin DoDot:1
+31 WRITE !,?5,"[ ] YES",!
+32 WRITE !,?5,"[X] NO",!
End DoDot:1
+33 IF $PIECE(MSPRES(9000037,AG("DA"),.09),U)=""
Begin DoDot:1
+34 WRITE !,?5,"[ ] YES",!
+35 WRITE !,?5,"[ ] NO",!
End DoDot:1
+36 ;
+37 WRITE !,?2,"4. Was the illness/injury due to a work related accident/condition ? ",!
+38 IF $PIECE(MSPRES(9000037,AG("DA"),.11),U)="NO"!($PIECE(MSPRES(9000037,AG("DA"),.11),U)="")
Begin DoDot:1
+39 WRITE !,?5,"[ ] YES Date of injury/illness: _______________"
+40 WRITE !!,?14,"Name and address of Workman's Compensation (WC) plan:",!
+41 WRITE !,?14,$EXTRACT(AGLINE("_"),1,50),!
+42 WRITE !,?14,$EXTRACT(AGLINE("_"),1,50),!
+43 WRITE !,?14,$EXTRACT(AGLINE("_"),1,50),!
+44 WRITE !,?14,"Patient's policy or identification number: _______________"
+45 WRITE !,?14,"Name and address of your employer:",!
+46 WRITE !,?14,$EXTRACT(AGLINE("_"),1,50),!
+47 WRITE !,?14,$EXTRACT(AGLINE("_"),1,50),!
+48 WRITE !,?14,$EXTRACT(AGLINE("_"),1,50),!
+49 IF $PIECE(MSPRES(9000037,AG("DA"),.11),U)="NO"
WRITE !,?5,"[X] NO - GO TO PART II"
+50 IF $PIECE(MSPRES(9000037,AG("DA"),.11),U)=""
WRITE !,?5,"[ ] NO - GO TO PART II"
End DoDot:1
+51 IF $PIECE(MSPRES(9000037,AG("DA"),.11),U)="YES"
Begin DoDot:1
+52 WRITE !,?5,"[X] YES "
+53 IF $PIECE(MSPRES(9000037,AG("DA"),.12),U)'=""
Begin DoDot:2
+54 WRITE "Date of injury/illness: ",$PIECE(MSPRES(9000037,AG("DA"),.12),U)
End DoDot:2
+55 IF $PIECE(MSPRES(9000037,AG("DA"),.12),U)=""
Begin DoDot:2
+56 WRITE "Date of injury/illness: _______________"
End DoDot:2
+57 WRITE !,?14,"Name and address of Workman's Compensation (WC) plan:",!
+58 IF $PIECE(MSPRES(9000037,AG("DA"),.13),U)=""
Begin DoDot:2
+59 WRITE !,?14,$EXTRACT(AGLINE("_"),1,50),!
+60 WRITE !,?14,$EXTRACT(AGLINE("_"),1,50),!
+61 WRITE !,?14,$EXTRACT(AGLINE("_"),1,50),!
End DoDot:2
+62 IF $PIECE(MSPRES(9000037,AG("DA"),.13),U)'=""
Begin DoDot:2
+63 SET AG("INSPTR")=$PIECE($GET(^AUPNMSP(AG("DA"),1)),U,8)
+64 SET AG("INSADDR")=$GET(^AUTNINS(AG("INSPTR"),0))
+65 ;INSURER NAME
WRITE !,?14,$PIECE(AG("INSADDR"),U),!
+66 ;INSURER STREET
WRITE !,?14,$PIECE(AG("INSADDR"),U,2),!
+67 ;INSURER CITY
WRITE !,?14,$PIECE(AG("INSADDR"),U,3)
+68 IF $PIECE(AG("INSADDR"),U,4)'=""
Begin DoDot:3
+69 ;INSURER STATE
WRITE ", ",$PIECE($GET(^DIC(5,$PIECE(AG("INSADDR"),U,4),0)),U,2)
End DoDot:3
+70 ;INSURER ZIP CODE
WRITE " ",$PIECE(AG("INSADDR"),U,5),!
End DoDot:2
+71 IF $PIECE(MSPRES(9000037,AG("DA"),.14),U)=""
Begin DoDot:2
+72 WRITE !!,?14,"Patient's policy or identification number: _______________"
End DoDot:2
+73 IF $PIECE(MSPRES(9000037,AG("DA"),.14),U)'=""
Begin DoDot:2
+74 WRITE !,?14,"Patient's policy or identification number: ",$PIECE(MSPRES(9000037,AG("DA"),.14),U)
End DoDot:2
+75 IF $PIECE(MSPRES(9000037,AG("DA"),.15),U)=""
Begin DoDot:2
+76 WRITE !,?14,"Name and address of your employer:",!
+77 WRITE !,?14,$EXTRACT(AGLINE("_"),1,50),!
+78 WRITE !,?14,$EXTRACT(AGLINE("_"),1,50),!
+79 WRITE !,?14,$EXTRACT(AGLINE("_"),1,50),!
End DoDot:2
+80 IF $PIECE(MSPRES(9000037,AG("DA"),.15),U)'=""
Begin DoDot:2
+81 SET AG("EMPPTR")=$PIECE($GET(^AUPNMSP(AG("DA"),1)),U,10)
+82 IF $GET(AG("EMPPTR"))'=""
Begin DoDot:3
+83 SET AG("EMPADDR")=$GET(^AUTNEMPL(AG("EMPPTR"),0))
+84 WRITE !,?14,"Name and address of your employer:",!
+85 ;EMPLOYER
WRITE !,?14,$PIECE(AG("EMPADDR"),U),!
+86 ;EMPLOYER STREET
WRITE !,?14,$PIECE(AG("EMPADDR"),U,2),!
+87 ;EMPLOYER CITY
WRITE !,?14,$PIECE(AG("EMPADDR"),U,3)
+88 ;EMPLOYER STATE
IF $PIECE(AG("EMPADDR"),U,4)'=""
WRITE ", ",$PIECE($GET(^DIC(5,$PIECE(AG("EMPADDR"),U,4),0)),U,2)
+89 ;EMPLOYER ZIP
WRITE ", ",$PIECE(AG("EMPADDR"),U,5),!
End DoDot:3
+90 IF $GET(AG("EMPPTR"))=""
Begin DoDot:3
+91 WRITE !,?14,$EXTRACT(AGLINE("_"),1,50),!
+92 WRITE !,?14,$EXTRACT(AGLINE("_"),1,50),!
+93 WRITE !,?14,$EXTRACT(AGLINE("_"),1,50),!
End DoDot:3
End DoDot:2
+94 WRITE !,?5,"[ ] NO - GO TO PART II",!
End DoDot:1
+95 KILL AG("INSPTR"),AG("INSADDR"),AG("EMPPTR"),AG("EMPADDR")
+96 QUIT
