- AGMSP4 ; IHS/ASDS/EFG - PRINT PAGE 4 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 IV - Age (con't)",!
- I '$D(AG("MSPPRINT")) D BLANK1
- I $D(AG("MSPPRINT")) D MAP1
- W !
- W !,?50,"Continued on next page ==>"
- W !,AGLINE("EQ")
- W !,$P($G(^DIC(4,DUZ(2),0)),U),?73,"PAGE 4"
- Q
- BLANK1 ;THIS SECTION IS USED TO PRINT THE BLANK PAGE 4
- W !,?2,"3. Do you have group health plan (GHP) coverage based on your own, or a"
- W !,?5,"spouse's current employment ? ",!
- W !,?5,"[ ] YES",!
- W !,?5,"[ ] NO. STOP. Medicare is primary payer unless the patient answered yes"
- W !?19,"to the questions in part I or II.",!
- W !,?2,"4. Does the employer that sponsors your GHP employ 20 or more employees ? ",!
- W !,?5,"[ ] YES. STOP. The GHP is primary. Obtain the following information:"
- W !,?14,"Name and address of GHP : ",!
- W !,?14,$E(AGLINE("_"),1,50),!
- W !,?14,$E(AGLINE("_"),1,50),!
- W !,?14,$E(AGLINE("_"),1,50),!
- W !,?14,"Policy Identification Number : _______________",!
- W !,?14,"Group Identification Number : _______________",!
- W !,?14,"Name of Policy Holder : ______________________",!
- W !,?14,"Relationship to Patient : ____________________",!
- W !,?5,"[ ] NO. STOP. Medicare is primary payer unless the patient answered"
- W !,!?20,"yes to questions in part I or II.",!
- W !,"PART V - Disability",!
- W !,?2,"1. Are you currently employed ? ",!
- W !,?5,"[ ] YES"
- 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 !,?5,"[ ] NO Date of retirement : _______________",!
- Q
- MAP1 ;THIS SECTION IS USED TO PRINT THE PATIENT'S DATA ON THE FORM
- W !,?2,"4. Does the employer that sponsors your GHP employ 20 or more employees ? ",!
- I $P(MSPRES(9000037,AG("DA"),.34),U)=""!($P(MSPRES(9000037,AG("DA"),.34),U)="NO") D
- . W !,?5,"[ ] YES",!
- . W !,?14,"Name and address of GHP : ",!
- . W !,?14,$E(AGLINE("_"),1,50),!
- . W !,?14,$E(AGLINE("_"),1,50),!
- . W !,?14,$E(AGLINE("_"),1,50),!
- . W !,?14,"Policy Identification Number : _______________",!
- . W !,?14,"Group Identification Number : _______________",!
- . W !,?14,"Name of Policy Holder : ______________________",!
- . W !,?14,"Relationship to Patient : ____________________",!
- . I $P(MSPRES(9000037,AG("DA"),.34),U)="" W !,?5,"[ ] NO",!
- . I $P(MSPRES(9000037,AG("DA"),.34),U)="NO" W !,?5,"[X] NO",!
- I $P(MSPRES(9000037,AG("DA"),.34),U)="YES" D
- . W !,?5,"[X] YES",!
- . W !,?14,"Name and address of GHP : ",!
- . I $P(MSPRES(9000037,AG("DA"),.35),U)="" D
- .. W !,?14,$E(AGLINE("_"),1,50),!
- .. W !,?14,$E(AGLINE("_"),1,50),!
- .. W !,?14,$E(AGLINE("_"),1,50),!
- . I $P(MSPRES(9000037,AG("DA"),.35),U)'="" D
- .. S AG("INSPTR")=$P($G(^AUPNMSP(AG("DA"),4)),U,9)
- .. S AG("INSADDR")=$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
- . I $P(MSPRES(9000037,AG("DA"),.36),U)="" D
- .. W !!,?14,"Policy Identification Number : _______________",!
- . I $P(MSPRES(9000037,AG("DA"),.36),U)'="" D
- .. W !!,?14,"Policy Identification Number : ",$P(MSPRES(9000037,AG("DA"),.36),U),!
- . I $P(MSPRES(9000037,AG("DA"),.37),U)="" D
- .. W !,?14,"Group Identification Number : _______________",!
- . I $P(MSPRES(9000037,AG("DA"),.37),U)'="" D
- .. W !,?14,"Group Identification Number : ",$P(MSPRES(9000037,AG("DA"),.37),U),!
- . I $P(MSPRES(9000037,AG("DA"),.38),U)="" D
- .. W !,?14,"Name of Policy Holder : ______________________",!
- . I $P(MSPRES(9000037,AG("DA"),.38),U)'="" D
- .. W !,?14,"Name of Policy Holder : ",$P(MSPRES(9000037,AG("DA"),.38),U),!
- . I $P(MSPRES(9000037,AG("DA"),.39),U)="" D
- .. W !,?14,"Relationship to Patient : ____________________",!
- . I $P(MSPRES(9000037,AG("DA"),.39),U)'="" D
- .. S AG("RELPTR")=$P($G(^AUPNMSP(AG("DA"),4)),U,13)
- .. W !,?14,"Relationship to Patient : ",$P($G(^AUTTRLSH(AG("RELPTR"),0)),U),!
- . W !,?5,"[ ] NO",!
- ;
- W !,"PART V - Disability",!
- W !,?2,"1. Are you currently employed ? ",!
- I $P(MSPRES(9000037,AG("DA"),.41),U)=""!($P(MSPRES(9000037,AG("DA"),.41),U)="NO") D
- . W !,?5,"[ ] YES",!
- . 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"),.41),U)="" W !,?5,"[ ] NO Date of retirement : _______________",!
- . I $P(MSPRES(9000037,AG("DA"),.41),U)="NO" D
- .. W !,?5,"[X] NO Date of retirement : "
- .. W $P(MSPRES(9000037,AG("DA"),.43),U),!
- I $P(MSPRES(9000037,AG("DA"),.41),U)="YES" D
- . S AG("EMPPTR")=$P($G(^AUPNMSP(AG("DA"),5)),U,2)
- . I $G(AG("EMPPTR"))'="" D
- .. S AG("EMPADDR")=$G(^AUTNEMPL(AG("EMPPTR"),0))
- .. W !,?5,"[X] YES",!
- .. W !,?14,"Name and address of your employer : ",!
- .. W !,?14,$P(AG("EMPADDR"),U),! ;EMPLOYER NAME
- .. W !,?14,$P(AG("EMPADDR"),U,2),! ;EMPLOYER STREET
- .. W !,?14,$P(AG("EMPADDR"),U,3) ;EMPLOYER CITY
- .. I $P(AG("EMPADDR"),U,4)'="" D
- ... W ", ",$P($G(^DIC(5,$P(AG("EMPADDR"),U,4),0)),U,2) ;EMPLOYER STATE
- .. W ", ",$P(AG("EMPADDR"),U,5),! ;EMPLOYER ZIP
- .. W !,?5,"[ ] NO Date of retirement : _______________",!
- . I $G(AG("EMPPTR"))="" D
- .. W !,?5,"[X] YES",!
- .. W !,?14,$E(AGLINE("_"),1,50),!
- .. W !,?14,$E(AGLINE("_"),1,50),!
- .. W !,?14,$E(AGLINE("_"),1,50),!
- .. W !,?5,"[ ] NO Date of retirement : _______________",!
- K AG("INSPTR"),AG("INSADDR"),AG("EMPPTR"),AG("EMPADDR"),AG("RELPTR")
- Q
- AGMSP4 ; IHS/ASDS/EFG - PRINT PAGE 4 OF MSP FORM ;
- +1 ;;7.1;PATIENT REGISTRATION;;AUG 25,2005
- +2 ;
- +3 ;I AG("MSPPRINT") EXISTS, MAP DATA FROM AUPNMSP TO THE FORM
- EN ;EP
- +1 WRITE !,"PART IV - Age (con't)",!
- +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($GET(^DIC(4,DUZ(2),0)),U),?73,"PAGE 4"
- +8 QUIT
- BLANK1 ;THIS SECTION IS USED TO PRINT THE BLANK PAGE 4
- +1 WRITE !,?2,"3. Do you have group health plan (GHP) coverage based on your own, or a"
- +2 WRITE !,?5,"spouse's current employment ? ",!
- +3 WRITE !,?5,"[ ] YES",!
- +4 WRITE !,?5,"[ ] NO. STOP. Medicare is primary payer unless the patient answered yes"
- +5 WRITE !?19,"to the questions in part I or II.",!
- +6 WRITE !,?2,"4. Does the employer that sponsors your GHP employ 20 or more employees ? ",!
- +7 WRITE !,?5,"[ ] YES. STOP. The GHP is primary. Obtain the following information:"
- +8 WRITE !,?14,"Name and address of GHP : ",!
- +9 WRITE !,?14,$EXTRACT(AGLINE("_"),1,50),!
- +10 WRITE !,?14,$EXTRACT(AGLINE("_"),1,50),!
- +11 WRITE !,?14,$EXTRACT(AGLINE("_"),1,50),!
- +12 WRITE !,?14,"Policy Identification Number : _______________",!
- +13 WRITE !,?14,"Group Identification Number : _______________",!
- +14 WRITE !,?14,"Name of Policy Holder : ______________________",!
- +15 WRITE !,?14,"Relationship to Patient : ____________________",!
- +16 WRITE !,?5,"[ ] NO. STOP. Medicare is primary payer unless the patient answered"
- +17 WRITE !,!?20,"yes to questions in part I or II.",!
- +18 WRITE !,"PART V - Disability",!
- +19 WRITE !,?2,"1. Are you currently employed ? ",!
- +20 WRITE !,?5,"[ ] YES"
- +21 WRITE !,?14,"Name and address of your employer : ",!
- +22 WRITE !,?14,$EXTRACT(AGLINE("_"),1,50),!
- +23 WRITE !,?14,$EXTRACT(AGLINE("_"),1,50),!
- +24 WRITE !,?14,$EXTRACT(AGLINE("_"),1,50),!
- +25 WRITE !,?5,"[ ] NO Date of retirement : _______________",!
- +26 QUIT
- MAP1 ;THIS SECTION IS USED TO PRINT THE PATIENT'S DATA ON THE FORM
- +1 WRITE !,?2,"4. Does the employer that sponsors your GHP employ 20 or more employees ? ",!
- +2 IF $PIECE(MSPRES(9000037,AG("DA"),.34),U)=""!($PIECE(MSPRES(9000037,AG("DA"),.34),U)="NO")
- Begin DoDot:1
- +3 WRITE !,?5,"[ ] YES",!
- +4 WRITE !,?14,"Name and address of GHP : ",!
- +5 WRITE !,?14,$EXTRACT(AGLINE("_"),1,50),!
- +6 WRITE !,?14,$EXTRACT(AGLINE("_"),1,50),!
- +7 WRITE !,?14,$EXTRACT(AGLINE("_"),1,50),!
- +8 WRITE !,?14,"Policy Identification Number : _______________",!
- +9 WRITE !,?14,"Group Identification Number : _______________",!
- +10 WRITE !,?14,"Name of Policy Holder : ______________________",!
- +11 WRITE !,?14,"Relationship to Patient : ____________________",!
- +12 IF $PIECE(MSPRES(9000037,AG("DA"),.34),U)=""
- WRITE !,?5,"[ ] NO",!
- +13 IF $PIECE(MSPRES(9000037,AG("DA"),.34),U)="NO"
- WRITE !,?5,"[X] NO",!
- End DoDot:1
- +14 IF $PIECE(MSPRES(9000037,AG("DA"),.34),U)="YES"
- Begin DoDot:1
- +15 WRITE !,?5,"[X] YES",!
- +16 WRITE !,?14,"Name and address of GHP : ",!
- +17 IF $PIECE(MSPRES(9000037,AG("DA"),.35),U)=""
- Begin DoDot:2
- +18 WRITE !,?14,$EXTRACT(AGLINE("_"),1,50),!
- +19 WRITE !,?14,$EXTRACT(AGLINE("_"),1,50),!
- +20 WRITE !,?14,$EXTRACT(AGLINE("_"),1,50),!
- End DoDot:2
- +21 IF $PIECE(MSPRES(9000037,AG("DA"),.35),U)'=""
- Begin DoDot:2
- +22 SET AG("INSPTR")=$PIECE($GET(^AUPNMSP(AG("DA"),4)),U,9)
- +23 SET AG("INSADDR")=$GET(^AUTNINS(AG("INSPTR"),0))
- +24 ;INSURER NAME
- WRITE !,?14,$PIECE(AG("INSADDR"),U),!
- +25 ;INSURER STREET
- WRITE !,?14,$PIECE(AG("INSADDR"),U,2),!
- +26 ;INSURER CITY
- WRITE !,?14,$PIECE(AG("INSADDR"),U,3)
- +27 IF $PIECE(AG("INSADDR"),U,4)'=""
- Begin DoDot:3
- +28 ;INSURER STATE
- WRITE ", ",$PIECE($GET(^DIC(5,$PIECE(AG("INSADDR"),U,4),0)),U,2)
- End DoDot:3
- +29 ;INSURER ZIP
- WRITE ", ",$PIECE(AG("INSADDR"),U,5),!
- End DoDot:2
- +30 IF $PIECE(MSPRES(9000037,AG("DA"),.36),U)=""
- Begin DoDot:2
- +31 WRITE !!,?14,"Policy Identification Number : _______________",!
- End DoDot:2
- +32 IF $PIECE(MSPRES(9000037,AG("DA"),.36),U)'=""
- Begin DoDot:2
- +33 WRITE !!,?14,"Policy Identification Number : ",$PIECE(MSPRES(9000037,AG("DA"),.36),U),!
- End DoDot:2
- +34 IF $PIECE(MSPRES(9000037,AG("DA"),.37),U)=""
- Begin DoDot:2
- +35 WRITE !,?14,"Group Identification Number : _______________",!
- End DoDot:2
- +36 IF $PIECE(MSPRES(9000037,AG("DA"),.37),U)'=""
- Begin DoDot:2
- +37 WRITE !,?14,"Group Identification Number : ",$PIECE(MSPRES(9000037,AG("DA"),.37),U),!
- End DoDot:2
- +38 IF $PIECE(MSPRES(9000037,AG("DA"),.38),U)=""
- Begin DoDot:2
- +39 WRITE !,?14,"Name of Policy Holder : ______________________",!
- End DoDot:2
- +40 IF $PIECE(MSPRES(9000037,AG("DA"),.38),U)'=""
- Begin DoDot:2
- +41 WRITE !,?14,"Name of Policy Holder : ",$PIECE(MSPRES(9000037,AG("DA"),.38),U),!
- End DoDot:2
- +42 IF $PIECE(MSPRES(9000037,AG("DA"),.39),U)=""
- Begin DoDot:2
- +43 WRITE !,?14,"Relationship to Patient : ____________________",!
- End DoDot:2
- +44 IF $PIECE(MSPRES(9000037,AG("DA"),.39),U)'=""
- Begin DoDot:2
- +45 SET AG("RELPTR")=$PIECE($GET(^AUPNMSP(AG("DA"),4)),U,13)
- +46 WRITE !,?14,"Relationship to Patient : ",$PIECE($GET(^AUTTRLSH(AG("RELPTR"),0)),U),!
- End DoDot:2
- +47 WRITE !,?5,"[ ] NO",!
- End DoDot:1
- +48 ;
- +49 WRITE !,"PART V - Disability",!
- +50 WRITE !,?2,"1. Are you currently employed ? ",!
- +51 IF $PIECE(MSPRES(9000037,AG("DA"),.41),U)=""!($PIECE(MSPRES(9000037,AG("DA"),.41),U)="NO")
- Begin DoDot:1
- +52 WRITE !,?5,"[ ] YES",!
- +53 WRITE !,?14,"Name and address of your employer : ",!
- +54 WRITE !,?14,$EXTRACT(AGLINE("_"),1,50),!
- +55 WRITE !,?14,$EXTRACT(AGLINE("_"),1,50),!
- +56 WRITE !,?14,$EXTRACT(AGLINE("_"),1,50),!
- +57 IF $PIECE(MSPRES(9000037,AG("DA"),.41),U)=""
- WRITE !,?5,"[ ] NO Date of retirement : _______________",!
- +58 IF $PIECE(MSPRES(9000037,AG("DA"),.41),U)="NO"
- Begin DoDot:2
- +59 WRITE !,?5,"[X] NO Date of retirement : "
- +60 WRITE $PIECE(MSPRES(9000037,AG("DA"),.43),U),!
- End DoDot:2
- End DoDot:1
- +61 IF $PIECE(MSPRES(9000037,AG("DA"),.41),U)="YES"
- Begin DoDot:1
- +62 SET AG("EMPPTR")=$PIECE($GET(^AUPNMSP(AG("DA"),5)),U,2)
- +63 IF $GET(AG("EMPPTR"))'=""
- Begin DoDot:2
- +64 SET AG("EMPADDR")=$GET(^AUTNEMPL(AG("EMPPTR"),0))
- +65 WRITE !,?5,"[X] YES",!
- +66 WRITE !,?14,"Name and address of your employer : ",!
- +67 ;EMPLOYER NAME
- WRITE !,?14,$PIECE(AG("EMPADDR"),U),!
- +68 ;EMPLOYER STREET
- WRITE !,?14,$PIECE(AG("EMPADDR"),U,2),!
- +69 ;EMPLOYER CITY
- WRITE !,?14,$PIECE(AG("EMPADDR"),U,3)
- +70 IF $PIECE(AG("EMPADDR"),U,4)'=""
- Begin DoDot:3
- +71 ;EMPLOYER STATE
- WRITE ", ",$PIECE($GET(^DIC(5,$PIECE(AG("EMPADDR"),U,4),0)),U,2)
- End DoDot:3
- +72 ;EMPLOYER ZIP
- WRITE ", ",$PIECE(AG("EMPADDR"),U,5),!
- +73 WRITE !,?5,"[ ] NO Date of retirement : _______________",!
- End DoDot:2
- +74 IF $GET(AG("EMPPTR"))=""
- Begin DoDot:2
- +75 WRITE !,?5,"[X] YES",!
- +76 WRITE !,?14,$EXTRACT(AGLINE("_"),1,50),!
- +77 WRITE !,?14,$EXTRACT(AGLINE("_"),1,50),!
- +78 WRITE !,?14,$EXTRACT(AGLINE("_"),1,50),!
- +79 WRITE !,?5,"[ ] NO Date of retirement : _______________",!
- End DoDot:2
- End DoDot:1
- +80 KILL AG("INSPTR"),AG("INSADDR"),AG("EMPPTR"),AG("EMPADDR"),AG("RELPTR")
- +81 QUIT