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Routine: AGMSP4

AGMSP4.m

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  1. AGMSP4 ; IHS/ASDS/EFG - PRINT PAGE 4 OF MSP FORM ;
  1. ;;7.1;PATIENT REGISTRATION;;AUG 25,2005
  1. ;
  1. ;I AG("MSPPRINT") EXISTS, MAP DATA FROM AUPNMSP TO THE FORM
  1. EN ;EP
  1. W !,"PART IV - Age (con't)",!
  1. I '$D(AG("MSPPRINT")) D BLANK1
  1. I $D(AG("MSPPRINT")) D MAP1
  1. W !
  1. W !,?50,"Continued on next page ==>"
  1. W !,AGLINE("EQ")
  1. W !,$P($G(^DIC(4,DUZ(2),0)),U),?73,"PAGE 4"
  1. Q
  1. BLANK1 ;THIS SECTION IS USED TO PRINT THE BLANK PAGE 4
  1. W !,?2,"3. Do you have group health plan (GHP) coverage based on your own, or a"
  1. W !,?5,"spouse's current employment ? ",!
  1. W !,?5,"[ ] YES",!
  1. W !,?5,"[ ] NO. STOP. Medicare is primary payer unless the patient answered yes"
  1. W !?19,"to the questions in part I or II.",!
  1. W !,?2,"4. Does the employer that sponsors your GHP employ 20 or more employees ? ",!
  1. W !,?5,"[ ] YES. STOP. The GHP is primary. Obtain the following information:"
  1. W !,?14,"Name and address of GHP : ",!
  1. W !,?14,$E(AGLINE("_"),1,50),!
  1. W !,?14,$E(AGLINE("_"),1,50),!
  1. W !,?14,$E(AGLINE("_"),1,50),!
  1. W !,?14,"Policy Identification Number : _______________",!
  1. W !,?14,"Group Identification Number : _______________",!
  1. W !,?14,"Name of Policy Holder : ______________________",!
  1. W !,?14,"Relationship to Patient : ____________________",!
  1. W !,?5,"[ ] NO. STOP. Medicare is primary payer unless the patient answered"
  1. W !,!?20,"yes to questions in part I or II.",!
  1. W !,"PART V - Disability",!
  1. W !,?2,"1. Are you currently employed ? ",!
  1. W !,?5,"[ ] YES"
  1. W !,?14,"Name and address of your employer : ",!
  1. W !,?14,$E(AGLINE("_"),1,50),!
  1. W !,?14,$E(AGLINE("_"),1,50),!
  1. W !,?14,$E(AGLINE("_"),1,50),!
  1. W !,?5,"[ ] NO Date of retirement : _______________",!
  1. Q
  1. MAP1 ;THIS SECTION IS USED TO PRINT THE PATIENT'S DATA ON THE FORM
  1. W !,?2,"4. Does the employer that sponsors your GHP employ 20 or more employees ? ",!
  1. I $P(MSPRES(9000037,AG("DA"),.34),U)=""!($P(MSPRES(9000037,AG("DA"),.34),U)="NO") D
  1. . W !,?5,"[ ] YES",!
  1. . W !,?14,"Name and address of GHP : ",!
  1. . W !,?14,$E(AGLINE("_"),1,50),!
  1. . W !,?14,$E(AGLINE("_"),1,50),!
  1. . W !,?14,$E(AGLINE("_"),1,50),!
  1. . W !,?14,"Policy Identification Number : _______________",!
  1. . W !,?14,"Group Identification Number : _______________",!
  1. . W !,?14,"Name of Policy Holder : ______________________",!
  1. . W !,?14,"Relationship to Patient : ____________________",!
  1. . I $P(MSPRES(9000037,AG("DA"),.34),U)="" W !,?5,"[ ] NO",!
  1. . I $P(MSPRES(9000037,AG("DA"),.34),U)="NO" W !,?5,"[X] NO",!
  1. I $P(MSPRES(9000037,AG("DA"),.34),U)="YES" D
  1. . W !,?5,"[X] YES",!
  1. . W !,?14,"Name and address of GHP : ",!
  1. . I $P(MSPRES(9000037,AG("DA"),.35),U)="" D
  1. .. W !,?14,$E(AGLINE("_"),1,50),!
  1. .. W !,?14,$E(AGLINE("_"),1,50),!
  1. .. W !,?14,$E(AGLINE("_"),1,50),!
  1. . I $P(MSPRES(9000037,AG("DA"),.35),U)'="" D
  1. .. S AG("INSPTR")=$P($G(^AUPNMSP(AG("DA"),4)),U,9)
  1. .. S AG("INSADDR")=$G(^AUTNINS(AG("INSPTR"),0))
  1. .. W !,?14,$P(AG("INSADDR"),U),! ;INSURER NAME
  1. .. W !,?14,$P(AG("INSADDR"),U,2),! ;INSURER STREET
  1. .. W !,?14,$P(AG("INSADDR"),U,3) ;INSURER CITY
  1. .. I $P(AG("INSADDR"),U,4)'="" D
  1. ... W ", ",$P($G(^DIC(5,$P(AG("INSADDR"),U,4),0)),U,2) ;INSURER STATE
  1. .. W ", ",$P(AG("INSADDR"),U,5),! ;INSURER ZIP
  1. . I $P(MSPRES(9000037,AG("DA"),.36),U)="" D
  1. .. W !!,?14,"Policy Identification Number : _______________",!
  1. . I $P(MSPRES(9000037,AG("DA"),.36),U)'="" D
  1. .. W !!,?14,"Policy Identification Number : ",$P(MSPRES(9000037,AG("DA"),.36),U),!
  1. . I $P(MSPRES(9000037,AG("DA"),.37),U)="" D
  1. .. W !,?14,"Group Identification Number : _______________",!
  1. . I $P(MSPRES(9000037,AG("DA"),.37),U)'="" D
  1. .. W !,?14,"Group Identification Number : ",$P(MSPRES(9000037,AG("DA"),.37),U),!
  1. . I $P(MSPRES(9000037,AG("DA"),.38),U)="" D
  1. .. W !,?14,"Name of Policy Holder : ______________________",!
  1. . I $P(MSPRES(9000037,AG("DA"),.38),U)'="" D
  1. .. W !,?14,"Name of Policy Holder : ",$P(MSPRES(9000037,AG("DA"),.38),U),!
  1. . I $P(MSPRES(9000037,AG("DA"),.39),U)="" D
  1. .. W !,?14,"Relationship to Patient : ____________________",!
  1. . I $P(MSPRES(9000037,AG("DA"),.39),U)'="" D
  1. .. S AG("RELPTR")=$P($G(^AUPNMSP(AG("DA"),4)),U,13)
  1. .. W !,?14,"Relationship to Patient : ",$P($G(^AUTTRLSH(AG("RELPTR"),0)),U),!
  1. . W !,?5,"[ ] NO",!
  1. ;
  1. W !,"PART V - Disability",!
  1. W !,?2,"1. Are you currently employed ? ",!
  1. I $P(MSPRES(9000037,AG("DA"),.41),U)=""!($P(MSPRES(9000037,AG("DA"),.41),U)="NO") D
  1. . W !,?5,"[ ] YES",!
  1. . W !,?14,"Name and address of your employer : ",!
  1. . W !,?14,$E(AGLINE("_"),1,50),!
  1. . W !,?14,$E(AGLINE("_"),1,50),!
  1. . W !,?14,$E(AGLINE("_"),1,50),!
  1. . I $P(MSPRES(9000037,AG("DA"),.41),U)="" W !,?5,"[ ] NO Date of retirement : _______________",!
  1. . I $P(MSPRES(9000037,AG("DA"),.41),U)="NO" D
  1. .. W !,?5,"[X] NO Date of retirement : "
  1. .. W $P(MSPRES(9000037,AG("DA"),.43),U),!
  1. I $P(MSPRES(9000037,AG("DA"),.41),U)="YES" D
  1. . S AG("EMPPTR")=$P($G(^AUPNMSP(AG("DA"),5)),U,2)
  1. . I $G(AG("EMPPTR"))'="" D
  1. .. S AG("EMPADDR")=$G(^AUTNEMPL(AG("EMPPTR"),0))
  1. .. W !,?5,"[X] YES",!
  1. .. W !,?14,"Name and address of your employer : ",!
  1. .. W !,?14,$P(AG("EMPADDR"),U),! ;EMPLOYER NAME
  1. .. W !,?14,$P(AG("EMPADDR"),U,2),! ;EMPLOYER STREET
  1. .. W !,?14,$P(AG("EMPADDR"),U,3) ;EMPLOYER CITY
  1. .. I $P(AG("EMPADDR"),U,4)'="" D
  1. ... W ", ",$P($G(^DIC(5,$P(AG("EMPADDR"),U,4),0)),U,2) ;EMPLOYER STATE
  1. .. W ", ",$P(AG("EMPADDR"),U,5),! ;EMPLOYER ZIP
  1. .. W !,?5,"[ ] NO Date of retirement : _______________",!
  1. . I $G(AG("EMPPTR"))="" D
  1. .. W !,?5,"[X] YES",!
  1. .. W !,?14,$E(AGLINE("_"),1,50),!
  1. .. W !,?14,$E(AGLINE("_"),1,50),!
  1. .. W !,?14,$E(AGLINE("_"),1,50),!
  1. .. W !,?5,"[ ] NO Date of retirement : _______________",!
  1. K AG("INSPTR"),AG("INSADDR"),AG("EMPPTR"),AG("EMPADDR"),AG("RELPTR")
  1. Q