- AGMSP5 ; IHS/ASDS/EFG - PRINT PAGE 5 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 V - Disability (con't)",!
- I '$D(AG("MSPPRINT")) D BLANK1
- I $D(AG("MSPPRINT")) D MAP1
- W !,?50,"Continued on next page ==>"
- W !,AGLINE("EQ")
- W !,$P($G(^DIC(4,DUZ(2),0)),U),?73,"PAGE 5"
- Q
- BLANK1 ;THIS SECTION IS USED TO PRINT THE BLANK PAGE 5
- W !,?2,"2. Is a family member currently employed ? "
- W !,?5,"[ ] YES"
- W !,?14,"Name and address of family member's employer : ",!
- W !,?14,$E(AGLINE("_"),1,50),!
- W !,?14,$E(AGLINE("_"),1,50),!
- W !,?14,$E(AGLINE("_"),1,50)
- W !,?5,"[ ] NO",!
- W !?2,"If the patient answers no to both questions 1 and 2, Medicare is primary"
- W !?2,"unless the patient answered yes to questions in part I or II."
- W !?2,"STOP. DO NOT PROCEED ANY FURTHER."
- W !!?2,"3. Do you have group health plan (GHP) coverage based on your own or a family"
- W !,?5,"member's current employment ? "
- W !,?5,"[ ] YES"
- W !,?5,"[ ] NO. STOP. Medicare is primary unless the patient answered yes to"
- W !?19,"questions in part I or II.",!
- W !,?2,"4. Does the employer that sponsors your GHP employ 100 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 unless the patient answered yes to"
- W !?19,"questions in part I or II.",!
- W !!!
- Q
- MAP1 ;THIS SECTION IS USED TO PRINT THE PATIENT'S DATA ON THE FORM
- W !,?2,"2. Is a family member currently employed ? ",!
- I $P(MSPRES(9000037,AG("DA"),.44),U)=""!($P(MSPRES(9000037,AG("DA"),.44),U)="NO") D
- . W !,?5,"[ ] YES",!
- . W !,?14,"Name and address of family member's 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"),.44),U)="" W !,?5,"[ ] NO",!
- . I $P(MSPRES(9000037,AG("DA"),.44),U)="NO" W !,?5,"[X] NO",!
- I $P(MSPRES(9000037,AG("DA"),.44),U)="YES" D
- . S AG("EMPPTR")=$P($G(^AUPNMSP(AG("DA"),5)),U,5)
- . I $G(AG("EMPPTR"))'="" D
- .. S AG("EMPADDR")=$G(^AUTNEMPL(AG("EMPPTR"),0))
- .. W !,?5,"[X] YES",!
- .. W !,?14,"Name and address of family member's 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",!
- . I $G(AG("EMPADDR"))="" D
- .. W !,?5,"[X] YES",!
- .. W !,?14,$E(AGLINE("_"),1,50),!
- .. W !,?14,$E(AGLINE("_"),1,50),!
- .. W !,?14,$E(AGLINE("_"),1,50),!
- .. W !,?5,"[ ] NO",!
- ;
- W !?2,"3. Do you have group health plan (GHP) coverage based on your own, or a family"
- W !,?5,"member's current employment ? ",!
- I $P(MSPRES(9000037,AG("DA"),.46),U)=""!($P(MSPRES(9000037,AG("DA"),.46),U)="NO") D
- . W !,?5,"[ ] YES",!
- . I $P(MSPRES(9000037,AG("DA"),.46),U)="" W !,?5,"[ ] NO",!
- . I $P(MSPRES(9000037,AG("DA"),.46),U)="NO" W !,?5,"[X] NO",!
- I $P(MSPRES(9000037,AG("DA"),.46),U)="YES" D
- . W !,?5,"[X] YES",!
- . W !,?5,"[ ] NO",!
- ;
- W !,?2,"4. Does the employer that sponsors your GHP employ 100 or more employees ? ",!
- I $P(MSPRES(9000037,AG("DA"),.47),U)=""!($P(MSPRES(9000037,AG("DA"),.47),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"),.47),U)="" W !,?5,"[ ] NO",!
- . I $P(MSPRES(9000037,AG("DA"),.47),U)="NO" W !,?5,"[X] NO",!
- I $P(MSPRES(9000037,AG("DA"),.47),U)="YES" D
- . W !,?5,"[X] YES",!
- . W !,?14,"Name and address of GHP : ",!
- . I $P(MSPRES(9000037,AG("DA"),.48),U)="" D
- .. W !,?14,$E(AGLINE("_"),1,50),!
- .. W !,?14,$E(AGLINE("_"),1,50),!
- .. W !,?14,$E(AGLINE("_"),1,50),!
- . I $P(MSPRES(9000037,AG("DA"),.48),U)'="" D
- .. S AG("INSPTR")=$P($G(^AUPNMSP(AG("DA"),5)),U,8)
- .. S AG("INSADDR")=$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
- . I $P(MSPRES(9000037,AG("DA"),.49),U)="" D
- .. W !,?14,"Policy Identification Number : _______________",!
- . I $P(MSPRES(9000037,AG("DA"),.49),U)'="" D
- .. W !,?14,"Policy Identification Number : ",$P(MSPRES(9000037,AG("DA"),.49),U),!
- . I $P(MSPRES(9000037,AG("DA"),.51),U)="" D
- .. W !,?14,"Group Identification Number : _______________",!
- . I $P(MSPRES(9000037,AG("DA"),.51),U)'="" D
- .. W !,?14,"Group Identification Number : ",$P(MSPRES(9000037,AG("DA"),.51),U),!
- . I $P(MSPRES(9000037,AG("DA"),.52),U)="" D
- .. W !,?14,"Name of Policy Holder : ______________________",!
- . I $P(MSPRES(9000037,AG("DA"),.52),U)'="" D
- .. W !,?14,"Name of Policy Holder : ",$P(MSPRES(9000037,AG("DA"),.52),U),!
- . I $P(MSPRES(9000037,AG("DA"),.53),U)="" D
- .. W !,?14,"Relationship to Patient : ____________________",!
- . I $P(MSPRES(9000037,AG("DA"),.53),U)'="" D
- .. S AG("RELPTR")=$P($G(^AUPNMSP(AG("DA"),5)),U,12)
- .. W !,?14,"Relationship to Patient : ",$P($G(^AUTTRLSH(AG("RELPTR"),0)),U),!
- . W !,?5,"[ ] NO",!
- K AG("INSPTR"),AG("INSADDR"),AG("EMPPTR"),AG("EMPADDR"),AG("RELPTR")
- Q
- AGMSP5 ; IHS/ASDS/EFG - PRINT PAGE 5 OF MSP FORM ;
- +1 ;;7.1;PATIENT REGISTRATION;;AUG 25,2005
- +2 ;
- +3 ;I AG("MSPPRINT") EXISTS, MAP DATA FROM AUPNMSP TO THE FORM
- EN ;EP
- +1 WRITE !,"PART V - Disability (con't)",!
- +2 IF '$DATA(AG("MSPPRINT"))
- DO BLANK1
- +3 IF $DATA(AG("MSPPRINT"))
- DO MAP1
- +4 WRITE !,?50,"Continued on next page ==>"
- +5 WRITE !,AGLINE("EQ")
- +6 WRITE !,$PIECE($GET(^DIC(4,DUZ(2),0)),U),?73,"PAGE 5"
- +7 QUIT
- BLANK1 ;THIS SECTION IS USED TO PRINT THE BLANK PAGE 5
- +1 WRITE !,?2,"2. Is a family member currently employed ? "
- +2 WRITE !,?5,"[ ] YES"
- +3 WRITE !,?14,"Name and address of family member's employer : ",!
- +4 WRITE !,?14,$EXTRACT(AGLINE("_"),1,50),!
- +5 WRITE !,?14,$EXTRACT(AGLINE("_"),1,50),!
- +6 WRITE !,?14,$EXTRACT(AGLINE("_"),1,50)
- +7 WRITE !,?5,"[ ] NO",!
- +8 WRITE !?2,"If the patient answers no to both questions 1 and 2, Medicare is primary"
- +9 WRITE !?2,"unless the patient answered yes to questions in part I or II."
- +10 WRITE !?2,"STOP. DO NOT PROCEED ANY FURTHER."
- +11 WRITE !!?2,"3. Do you have group health plan (GHP) coverage based on your own or a family"
- +12 WRITE !,?5,"member's current employment ? "
- +13 WRITE !,?5,"[ ] YES"
- +14 WRITE !,?5,"[ ] NO. STOP. Medicare is primary unless the patient answered yes to"
- +15 WRITE !?19,"questions in part I or II.",!
- +16 WRITE !,?2,"4. Does the employer that sponsors your GHP employ 100 or more employees ? ",!
- +17 WRITE !,?5,"[ ] YES. STOP. The GHP is primary. Obtain the following information:",!
- +18 WRITE !,?14,"Name and address of GHP : ",!
- +19 WRITE !,?14,$EXTRACT(AGLINE("_"),1,50),!
- +20 WRITE !,?14,$EXTRACT(AGLINE("_"),1,50),!
- +21 WRITE !,?14,$EXTRACT(AGLINE("_"),1,50),!
- +22 WRITE !,?14,"Policy Identification Number : _______________",!
- +23 WRITE !,?14,"Group Identification Number : _______________",!
- +24 WRITE !,?14,"Name of Policy Holder : ______________________",!
- +25 WRITE !,?14,"Relationship to Patient : ____________________",!
- +26 WRITE !,?5,"[ ] NO. STOP. Medicare is primary unless the patient answered yes to"
- +27 WRITE !?19,"questions in part I or II.",!
- +28 WRITE !!!
- +29 QUIT
- MAP1 ;THIS SECTION IS USED TO PRINT THE PATIENT'S DATA ON THE FORM
- +1 WRITE !,?2,"2. Is a family member currently employed ? ",!
- +2 IF $PIECE(MSPRES(9000037,AG("DA"),.44),U)=""!($PIECE(MSPRES(9000037,AG("DA"),.44),U)="NO")
- Begin DoDot:1
- +3 WRITE !,?5,"[ ] YES",!
- +4 WRITE !,?14,"Name and address of family member's employer : ",!
- +5 WRITE !,?14,$EXTRACT(AGLINE("_"),1,50),!
- +6 WRITE !,?14,$EXTRACT(AGLINE("_"),1,50),!
- +7 WRITE !,?14,$EXTRACT(AGLINE("_"),1,50),!
- +8 IF $PIECE(MSPRES(9000037,AG("DA"),.44),U)=""
- WRITE !,?5,"[ ] NO",!
- +9 IF $PIECE(MSPRES(9000037,AG("DA"),.44),U)="NO"
- WRITE !,?5,"[X] NO",!
- End DoDot:1
- +10 IF $PIECE(MSPRES(9000037,AG("DA"),.44),U)="YES"
- Begin DoDot:1
- +11 SET AG("EMPPTR")=$PIECE($GET(^AUPNMSP(AG("DA"),5)),U,5)
- +12 IF $GET(AG("EMPPTR"))'=""
- Begin DoDot:2
- +13 SET AG("EMPADDR")=$GET(^AUTNEMPL(AG("EMPPTR"),0))
- +14 WRITE !,?5,"[X] YES",!
- +15 WRITE !,?14,"Name and address of family member's employer : ",!
- +16 ;EMPLOYER NAME
- WRITE !,?14,$PIECE(AG("EMPADDR"),U),!
- +17 ;EMPLOYER STREET
- WRITE !,?14,$PIECE(AG("EMPADDR"),U,2),!
- +18 ;EMPLOYER CITY
- WRITE !,?14,$PIECE(AG("EMPADDR"),U,3)
- +19 IF $PIECE(AG("EMPADDR"),U,4)'=""
- Begin DoDot:3
- +20 ;EMPLOYER STATE
- WRITE ", ",$PIECE($GET(^DIC(5,$PIECE(AG("EMPADDR"),U,4),0)),U,2)
- End DoDot:3
- +21 ;EMPLOYER ZIP
- WRITE ", ",$PIECE(AG("EMPADDR"),U,5),!
- +22 WRITE !,?5,"[ ] NO",!
- End DoDot:2
- +23 IF $GET(AG("EMPADDR"))=""
- Begin DoDot:2
- +24 WRITE !,?5,"[X] YES",!
- +25 WRITE !,?14,$EXTRACT(AGLINE("_"),1,50),!
- +26 WRITE !,?14,$EXTRACT(AGLINE("_"),1,50),!
- +27 WRITE !,?14,$EXTRACT(AGLINE("_"),1,50),!
- +28 WRITE !,?5,"[ ] NO",!
- End DoDot:2
- End DoDot:1
- +29 ;
- +30 WRITE !?2,"3. Do you have group health plan (GHP) coverage based on your own, or a family"
- +31 WRITE !,?5,"member's current employment ? ",!
- +32 IF $PIECE(MSPRES(9000037,AG("DA"),.46),U)=""!($PIECE(MSPRES(9000037,AG("DA"),.46),U)="NO")
- Begin DoDot:1
- +33 WRITE !,?5,"[ ] YES",!
- +34 IF $PIECE(MSPRES(9000037,AG("DA"),.46),U)=""
- WRITE !,?5,"[ ] NO",!
- +35 IF $PIECE(MSPRES(9000037,AG("DA"),.46),U)="NO"
- WRITE !,?5,"[X] NO",!
- End DoDot:1
- +36 IF $PIECE(MSPRES(9000037,AG("DA"),.46),U)="YES"
- Begin DoDot:1
- +37 WRITE !,?5,"[X] YES",!
- +38 WRITE !,?5,"[ ] NO",!
- End DoDot:1
- +39 ;
- +40 WRITE !,?2,"4. Does the employer that sponsors your GHP employ 100 or more employees ? ",!
- +41 IF $PIECE(MSPRES(9000037,AG("DA"),.47),U)=""!($PIECE(MSPRES(9000037,AG("DA"),.47),U)="NO")
- Begin DoDot:1
- +42 WRITE !,?5,"[ ] YES",!
- +43 WRITE !,?14,"Name and address of GHP : ",!
- +44 WRITE !,?14,$EXTRACT(AGLINE("_"),1,50),!
- +45 WRITE !,?14,$EXTRACT(AGLINE("_"),1,50),!
- +46 WRITE !,?14,$EXTRACT(AGLINE("_"),1,50),!
- +47 WRITE !,?14,"Policy Identification Number : _______________",!
- +48 WRITE !,?14,"Group Identification Number : _______________",!
- +49 WRITE !,?14,"Name of Policy Holder : ______________________",!
- +50 WRITE !,?14,"Relationship to Patient : ____________________",!
- +51 IF $PIECE(MSPRES(9000037,AG("DA"),.47),U)=""
- WRITE !,?5,"[ ] NO",!
- +52 IF $PIECE(MSPRES(9000037,AG("DA"),.47),U)="NO"
- WRITE !,?5,"[X] NO",!
- End DoDot:1
- +53 IF $PIECE(MSPRES(9000037,AG("DA"),.47),U)="YES"
- Begin DoDot:1
- +54 WRITE !,?5,"[X] YES",!
- +55 WRITE !,?14,"Name and address of GHP : ",!
- +56 IF $PIECE(MSPRES(9000037,AG("DA"),.48),U)=""
- Begin DoDot:2
- +57 WRITE !,?14,$EXTRACT(AGLINE("_"),1,50),!
- +58 WRITE !,?14,$EXTRACT(AGLINE("_"),1,50),!
- +59 WRITE !,?14,$EXTRACT(AGLINE("_"),1,50),!
- End DoDot:2
- +60 IF $PIECE(MSPRES(9000037,AG("DA"),.48),U)'=""
- Begin DoDot:2
- +61 SET AG("INSPTR")=$PIECE($GET(^AUPNMSP(AG("DA"),5)),U,8)
- +62 SET AG("INSADDR")=$GET(^AUTNINS(AG("INSPTR"),0))
- +63 ;INSURER NAME
- WRITE !,?14,$PIECE(AG("INSADDR"),U),!
- +64 ;INSURER STREET
- WRITE !,?14,$PIECE(AG("INSADDR"),U,2),!
- +65 ;INSURER CITY
- WRITE !,?14,$PIECE(AG("INSADDR"),U,3)
- +66 IF $PIECE(AG("INSADDR"),U,4)'=""
- Begin DoDot:3
- +67 ;INSURER STATE
- WRITE ", ",$PIECE($GET(^DIC(5,$PIECE(AG("INSADDR"),U,4),0)),U,2)
- End DoDot:3
- +68 ;INSURER ZIP
- WRITE ", ",$PIECE(AG("INSADDR"),U,5),!
- End DoDot:2
- +69 IF $PIECE(MSPRES(9000037,AG("DA"),.49),U)=""
- Begin DoDot:2
- +70 WRITE !,?14,"Policy Identification Number : _______________",!
- End DoDot:2
- +71 IF $PIECE(MSPRES(9000037,AG("DA"),.49),U)'=""
- Begin DoDot:2
- +72 WRITE !,?14,"Policy Identification Number : ",$PIECE(MSPRES(9000037,AG("DA"),.49),U),!
- End DoDot:2
- +73 IF $PIECE(MSPRES(9000037,AG("DA"),.51),U)=""
- Begin DoDot:2
- +74 WRITE !,?14,"Group Identification Number : _______________",!
- End DoDot:2
- +75 IF $PIECE(MSPRES(9000037,AG("DA"),.51),U)'=""
- Begin DoDot:2
- +76 WRITE !,?14,"Group Identification Number : ",$PIECE(MSPRES(9000037,AG("DA"),.51),U),!
- End DoDot:2
- +77 IF $PIECE(MSPRES(9000037,AG("DA"),.52),U)=""
- Begin DoDot:2
- +78 WRITE !,?14,"Name of Policy Holder : ______________________",!
- End DoDot:2
- +79 IF $PIECE(MSPRES(9000037,AG("DA"),.52),U)'=""
- Begin DoDot:2
- +80 WRITE !,?14,"Name of Policy Holder : ",$PIECE(MSPRES(9000037,AG("DA"),.52),U),!
- End DoDot:2
- +81 IF $PIECE(MSPRES(9000037,AG("DA"),.53),U)=""
- Begin DoDot:2
- +82 WRITE !,?14,"Relationship to Patient : ____________________",!
- End DoDot:2
- +83 IF $PIECE(MSPRES(9000037,AG("DA"),.53),U)'=""
- Begin DoDot:2
- +84 SET AG("RELPTR")=$PIECE($GET(^AUPNMSP(AG("DA"),5)),U,12)
- +85 WRITE !,?14,"Relationship to Patient : ",$PIECE($GET(^AUTTRLSH(AG("RELPTR"),0)),U),!
- End DoDot:2
- +86 WRITE !,?5,"[ ] NO",!
- End DoDot:1
- +87 KILL AG("INSPTR"),AG("INSADDR"),AG("EMPPTR"),AG("EMPADDR"),AG("RELPTR")
- +88 QUIT
