- AGMSP6 ; IHS/ASDS/EFG - PRINT PAGE 6 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 VI - ESRD",!
- I '$D(AG("MSPPRINT")) D BLANK1
- I $D(AG("MSPPRINT")) D MAP1
- W !
- W !,?50,"Continued on next page ==>"
- W !,AGLINE("EQ")
- W !,$P($G(^DIC(4,DUZ(2),0)),U),?73,"PAGE 6"
- Q
- BLANK1 ;THIS SECTION IS USED TO PRINT THE BLANK PAGE 6
- W !,?2,"1. Do you have group health plan (GHP) coverage ? ",!
- W !,?5,"[ ] YES",!
- W !,?14,"Name and address of GHP : ",!
- W !,?14,$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 : ____________________",!
- W !,?14,"Name and address of employer, if any, from which you receive"
- W !,?14,"GHP coverage : ",!
- W !,?14,$E(AGLINE("_"),1,50),!
- W !,?14,$E(AGLINE("_"),1,50),!
- W !,?14,$E(AGLINE("_"),1,50),!
- W !,?5,"[ ] NO. STOP. Medicare is primary.",!
- W !,?2,"2. Have you received a kidney transplant ? ",!
- W !,?5,"[ ] YES Date of transplant : _______________",!
- W !,?5,"[ ] NO",!
- W !,?2,"3. Have you received maintenance dialysis treatments ? ",!
- W !,?5,"[ ] YES Date dialysis began : _______________",!
- W !,?19,"If you participated in a self dialysis training"
- W !,?19,"program, provide date training started : _______________",!
- W !,?5,"[ ] NO",!
- Q
- MAP1 ;THIS SECTION IS USED TO PRINT THE PATIENT'S DATA ON THE FORM
- W !,?2,"1. Do you have group health plan (GHP) coverage ? ",!
- I $P(MSPRES(9000037,AG("DA"),.54),U)=""!($P(MSPRES(9000037,AG("DA"),.54),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,$E(AGLINE("_"),1,50),!
- . W !,?14,"Policy Identification Number : _______________",!
- . W !,?14,"Group Identification Number : _______________",!
- . W !,?14,"Name of Policy Holder : ______________________",!
- . W !,?14,"Relationship to Patient : ____________________",!
- . W !,?14,"Name and address of employer, if any, from which you receive"
- . W !,?14,"GHP coverage : ",!
- . W !,?14,$E(AGLINE("_"),1,50),!
- . W !,?14,$E(AGLINE("_"),1,50),!
- . W !,?14,$E(AGLINE("_"),1,50),!
- . I $P(MSPRES(9000037,AG("DA"),.54),U)="" W !,?5,"[ ] NO",!
- . I $P(MSPRES(9000037,AG("DA"),.54),U)="NO" W !,?5,"[X] NO",!
- I $P(MSPRES(9000037,AG("DA"),.54),U)="YES" D
- . W !,?5,"[X] YES",!
- . W !,?14,"Name and address of GHP : ",!
- . I $P(MSPRES(9000037,AG("DA"),.55),U)="" D
- .. W !,?14,$E(AGLINE("_"),1,50),!
- .. W !,?14,$E(AGLINE("_"),1,50),!
- .. W !,?14,$E(AGLINE("_"),1,50),!
- . I $P(MSPRES(9000037,AG("DA"),.55),U)'="" D
- .. S AG("INSPTR")=$P($G(^AUPNMSP(AG("DA"),6)),U,2)
- .. S AG("INSADDR")=$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(^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"),.56),U)="" D
- .. W !,?14,"Policy Identification Number : _______________",!
- . I $P(MSPRES(9000037,AG("DA"),.56),U)'="" D
- .. W !,?14,"Policy Identification Number : ",$P(MSPRES(9000037,AG("DA"),.56),U),!
- . I $P(MSPRES(9000037,AG("DA"),.57),U)="" D
- .. W !,?14,"Group Identification Number : _______________",!
- . I $P(MSPRES(9000037,AG("DA"),.57),U)'="" D
- .. W !,?14,"Group Identification Number : ",$P(MSPRES(9000037,AG("DA"),.57),U),!
- . I $P(MSPRES(9000037,AG("DA"),.58),U)="" D
- .. W !,?14,"Name of Policy Holder : ______________________",!
- . I $P(MSPRES(9000037,AG("DA"),.58),U)'="" D
- .. W !,?14,"Name of Policy Holder : ",$P(MSPRES(9000037,AG("DA"),.58),U),!
- . I $P(MSPRES(9000037,AG("DA"),.59),U)="" D
- .. W !,?14,"Relationship to Patient : ____________________",!
- . I $P(MSPRES(9000037,AG("DA"),.59),U)'="" D
- .. S AG("RELPTR")=$P($G(^AUPNMSP(AG("DA"),6)),U,6)
- .. W !,?14,"Relationship to Patient : ",$P($G(^AUTTRLSH(AG("RELPTR"),0)),U),!
- . W !,?14,"Name and address of employer, if any, from which you receive"
- . W !,?14,"GHP coverage : ",!
- . I $P(MSPRES(9000037,AG("DA"),.61),U)="" D
- .. W !,?14,$E(AGLINE("_"),1,50),!
- .. W !,?14,$E(AGLINE("_"),1,50),!
- .. W !,?14,$E(AGLINE("_"),1,50),!
- . I $P(MSPRES(9000037,AG("DA"),.61),U)'="" D
- .. S AG("EMPPTR")=$P($G(^AUPNMSP(AG("DA"),6)),U,7)
- .. I $G(AG("EMPPTR"))'="" D
- ... S AG("EMPADDR")=$G(^AUTNEMPL(AG("EMPPTR"),0))
- ... 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",!
- ;
- W !,?2,"2. Have you received a kidney transplant ? ",!
- I $P(MSPRES(9000037,AG("DA"),.62),U)=""!($P(MSPRES(9000037,AG("DA"),.62),U)="NO") D
- . W !,?5,"[ ] YES Date of transplant : _______________",!
- . I $P(MSPRES(9000037,AG("DA"),.62),U)="" W !,?5,"[ ] NO",!
- . I $P(MSPRES(9000037,AG("DA"),.62),U)="NO" W !,?5,"[X] NO",!
- I $P(MSPRES(9000037,AG("DA"),.62),U)="YES" D
- . W !,?5,"[X] YES "
- . I $P(MSPRES(9000037,AG("DA"),.63),U)="" W "Date of transplant : _______________",!
- . I $P(MSPRES(9000037,AG("DA"),.63),U)'="" W "Date of transplant : ",$P(MSPRES(9000037,AG("DA"),.63),U),!
- . W !,?5,"[ ] NO",!
- ;
- W !,?2,"3. Have you received maintenance dialysis treatments ? ",!
- I $P(MSPRES(9000037,AG("DA"),.64),U)=""!($P(MSPRES(9000037,AG("DA"),.64),U)="NO") D
- . W !,?5,"[ ] YES Date dialysis began : _______________",!
- . W !,?14,"If you participated in a self dialysis training"
- . W !,?14,"program, provide date training started : _______________",!
- . I $P(MSPRES(9000037,AG("DA"),.64),U)="" W !,?5,"[ ] NO",!
- . I $P(MSPRES(9000037,AG("DA"),.64),U)="NO" W !,?5,"[X] NO",!
- I $P(MSPRES(9000037,AG("DA"),.64),U)="YES" D
- . W !,?5,"[X] YES Date dialysis began : "
- . I $P(MSPRES(9000037,AG("DA"),.65),U)="" W "_______________",!
- . I $P(MSPRES(9000037,AG("DA"),.65),U)'="" W $P(MSPRES(9000037,AG("DA"),.65),U),!
- . W !,?14,"If you participated in a self dialysis training"
- . W !,?14,"program, provide date training started : "
- . I $P(MSPRES(9000037,AG("DA"),.66),U)="" W "_______________",!
- . I $P(MSPRES(9000037,AG("DA"),.66),U)'="" W $P(MSPRES(9000037,AG("DA"),.66),U),!
- . W !,?5,"[ ] NO",!
- K AG("INSPTR"),AG("INSADDR"),AG("EMPPTR"),AG("EMPADDR"),AG("RELPTR")
- Q
- AGMSP6 ; IHS/ASDS/EFG - PRINT PAGE 6 OF MSP FORM ;
- +1 ;;7.1;PATIENT REGISTRATION;;AUG 25,2005
- +2 ;
- +3 ;I AG("MSPPRINT") EXISTS, MAP DATA FROM AUPNMSP TO THE FORM
- EN ;EP
- +1 WRITE !,"PART VI - ESRD",!
- +2 IF '$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($GET(^DIC(4,DUZ(2),0)),U),?73,"PAGE 6"
- +8 QUIT
- BLANK1 ;THIS SECTION IS USED TO PRINT THE BLANK PAGE 6
- +1 WRITE !,?2,"1. Do you have group health plan (GHP) coverage ? ",!
- +2 WRITE !,?5,"[ ] YES",!
- +3 WRITE !,?14,"Name and address of GHP : ",!
- +4 WRITE !,?14,$EXTRACT(AGLINE("_"),1,50),!
- +5 WRITE !,?14,$EXTRACT(AGLINE("_"),1,50),!
- +6 WRITE !,?14,$EXTRACT(AGLINE("_"),1,50),!
- +7 WRITE !,?14,"Policy Identification Number : _______________",!
- +8 WRITE !,?14,"Group Identification Number : _______________",!
- +9 WRITE !,?14,"Name of Policy Holder : ______________________",!
- +10 WRITE !,?14,"Relationship to Patient : ____________________",!
- +11 WRITE !,?14,"Name and address of employer, if any, from which you receive"
- +12 WRITE !,?14,"GHP coverage : ",!
- +13 WRITE !,?14,$EXTRACT(AGLINE("_"),1,50),!
- +14 WRITE !,?14,$EXTRACT(AGLINE("_"),1,50),!
- +15 WRITE !,?14,$EXTRACT(AGLINE("_"),1,50),!
- +16 WRITE !,?5,"[ ] NO. STOP. Medicare is primary.",!
- +17 WRITE !,?2,"2. Have you received a kidney transplant ? ",!
- +18 WRITE !,?5,"[ ] YES Date of transplant : _______________",!
- +19 WRITE !,?5,"[ ] NO",!
- +20 WRITE !,?2,"3. Have you received maintenance dialysis treatments ? ",!
- +21 WRITE !,?5,"[ ] YES Date dialysis began : _______________",!
- +22 WRITE !,?19,"If you participated in a self dialysis training"
- +23 WRITE !,?19,"program, provide date training started : _______________",!
- +24 WRITE !,?5,"[ ] NO",!
- +25 QUIT
- MAP1 ;THIS SECTION IS USED TO PRINT THE PATIENT'S DATA ON THE FORM
- +1 WRITE !,?2,"1. Do you have group health plan (GHP) coverage ? ",!
- +2 IF $PIECE(MSPRES(9000037,AG("DA"),.54),U)=""!($PIECE(MSPRES(9000037,AG("DA"),.54),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,$EXTRACT(AGLINE("_"),1,50),!
- +8 WRITE !,?14,"Policy Identification Number : _______________",!
- +9 WRITE !,?14,"Group Identification Number : _______________",!
- +10 WRITE !,?14,"Name of Policy Holder : ______________________",!
- +11 WRITE !,?14,"Relationship to Patient : ____________________",!
- +12 WRITE !,?14,"Name and address of employer, if any, from which you receive"
- +13 WRITE !,?14,"GHP coverage : ",!
- +14 WRITE !,?14,$EXTRACT(AGLINE("_"),1,50),!
- +15 WRITE !,?14,$EXTRACT(AGLINE("_"),1,50),!
- +16 WRITE !,?14,$EXTRACT(AGLINE("_"),1,50),!
- +17 IF $PIECE(MSPRES(9000037,AG("DA"),.54),U)=""
- WRITE !,?5,"[ ] NO",!
- +18 IF $PIECE(MSPRES(9000037,AG("DA"),.54),U)="NO"
- WRITE !,?5,"[X] NO",!
- End DoDot:1
- +19 IF $PIECE(MSPRES(9000037,AG("DA"),.54),U)="YES"
- Begin DoDot:1
- +20 WRITE !,?5,"[X] YES",!
- +21 WRITE !,?14,"Name and address of GHP : ",!
- +22 IF $PIECE(MSPRES(9000037,AG("DA"),.55),U)=""
- Begin DoDot:2
- +23 WRITE !,?14,$EXTRACT(AGLINE("_"),1,50),!
- +24 WRITE !,?14,$EXTRACT(AGLINE("_"),1,50),!
- +25 WRITE !,?14,$EXTRACT(AGLINE("_"),1,50),!
- End DoDot:2
- +26 IF $PIECE(MSPRES(9000037,AG("DA"),.55),U)'=""
- Begin DoDot:2
- +27 SET AG("INSPTR")=$PIECE($GET(^AUPNMSP(AG("DA"),6)),U,2)
- +28 SET AG("INSADDR")=$GET(^AUTNINS(AG("INSPTR"),0))
- +29 ;INSURER NAME
- WRITE !,?14,$PIECE(AG("INSADDR"),U),!
- +30 ;INSURER STREET
- WRITE !,?14,$PIECE(AG("INSADDR"),U,2),!
- +31 ;INSURER CITY
- WRITE !,?14,$PIECE(AG("INSADDR"),U,3)
- +32 IF $PIECE(AG("INSADDR"),U,4)'=""
- Begin DoDot:3
- +33 ;INSURER STATE
- WRITE ", ",$PIECE(^DIC(5,$PIECE(AG("INSADDR"),U,4),0),U,2)
- End DoDot:3
- +34 ;INSURER ZIP
- WRITE ", ",$PIECE(AG("INSADDR"),U,5),!
- End DoDot:2
- +35 IF $PIECE(MSPRES(9000037,AG("DA"),.56),U)=""
- Begin DoDot:2
- +36 WRITE !,?14,"Policy Identification Number : _______________",!
- End DoDot:2
- +37 IF $PIECE(MSPRES(9000037,AG("DA"),.56),U)'=""
- Begin DoDot:2
- +38 WRITE !,?14,"Policy Identification Number : ",$PIECE(MSPRES(9000037,AG("DA"),.56),U),!
- End DoDot:2
- +39 IF $PIECE(MSPRES(9000037,AG("DA"),.57),U)=""
- Begin DoDot:2
- +40 WRITE !,?14,"Group Identification Number : _______________",!
- End DoDot:2
- +41 IF $PIECE(MSPRES(9000037,AG("DA"),.57),U)'=""
- Begin DoDot:2
- +42 WRITE !,?14,"Group Identification Number : ",$PIECE(MSPRES(9000037,AG("DA"),.57),U),!
- End DoDot:2
- +43 IF $PIECE(MSPRES(9000037,AG("DA"),.58),U)=""
- Begin DoDot:2
- +44 WRITE !,?14,"Name of Policy Holder : ______________________",!
- End DoDot:2
- +45 IF $PIECE(MSPRES(9000037,AG("DA"),.58),U)'=""
- Begin DoDot:2
- +46 WRITE !,?14,"Name of Policy Holder : ",$PIECE(MSPRES(9000037,AG("DA"),.58),U),!
- End DoDot:2
- +47 IF $PIECE(MSPRES(9000037,AG("DA"),.59),U)=""
- Begin DoDot:2
- +48 WRITE !,?14,"Relationship to Patient : ____________________",!
- End DoDot:2
- +49 IF $PIECE(MSPRES(9000037,AG("DA"),.59),U)'=""
- Begin DoDot:2
- +50 SET AG("RELPTR")=$PIECE($GET(^AUPNMSP(AG("DA"),6)),U,6)
- +51 WRITE !,?14,"Relationship to Patient : ",$PIECE($GET(^AUTTRLSH(AG("RELPTR"),0)),U),!
- End DoDot:2
- +52 WRITE !,?14,"Name and address of employer, if any, from which you receive"
- +53 WRITE !,?14,"GHP coverage : ",!
- +54 IF $PIECE(MSPRES(9000037,AG("DA"),.61),U)=""
- Begin DoDot:2
- +55 WRITE !,?14,$EXTRACT(AGLINE("_"),1,50),!
- +56 WRITE !,?14,$EXTRACT(AGLINE("_"),1,50),!
- +57 WRITE !,?14,$EXTRACT(AGLINE("_"),1,50),!
- End DoDot:2
- +58 IF $PIECE(MSPRES(9000037,AG("DA"),.61),U)'=""
- Begin DoDot:2
- +59 SET AG("EMPPTR")=$PIECE($GET(^AUPNMSP(AG("DA"),6)),U,7)
- +60 IF $GET(AG("EMPPTR"))'=""
- Begin DoDot:3
- +61 SET AG("EMPADDR")=$GET(^AUTNEMPL(AG("EMPPTR"),0))
- +62 ;EMPLOYER NAME
- WRITE !,?14,$PIECE(AG("EMPADDR"),U),!
- +63 ;EMPLOYER STREET
- WRITE !,?14,$PIECE(AG("EMPADDR"),U,2),!
- +64 ;EMPLOYER CITY
- WRITE !,?14,$PIECE(AG("EMPADDR"),U,3)
- +65 IF $PIECE(AG("EMPADDR"),U,4)'=""
- Begin DoDot:4
- +66 ;EMPLOYER STATE
- WRITE ", ",$PIECE($GET(^DIC(5,$PIECE(AG("EMPADDR"),U,4),0)),U,2)
- End DoDot:4
- +67 ;EMPLOYER ZIP
- WRITE ", ",$PIECE(AG("EMPADDR"),U,5),!
- End DoDot:3
- End DoDot:2
- +68 WRITE !,?5,"[ ] NO",!
- End DoDot:1
- +69 ;
- +70 WRITE !,?2,"2. Have you received a kidney transplant ? ",!
- +71 IF $PIECE(MSPRES(9000037,AG("DA"),.62),U)=""!($PIECE(MSPRES(9000037,AG("DA"),.62),U)="NO")
- Begin DoDot:1
- +72 WRITE !,?5,"[ ] YES Date of transplant : _______________",!
- +73 IF $PIECE(MSPRES(9000037,AG("DA"),.62),U)=""
- WRITE !,?5,"[ ] NO",!
- +74 IF $PIECE(MSPRES(9000037,AG("DA"),.62),U)="NO"
- WRITE !,?5,"[X] NO",!
- End DoDot:1
- +75 IF $PIECE(MSPRES(9000037,AG("DA"),.62),U)="YES"
- Begin DoDot:1
- +76 WRITE !,?5,"[X] YES "
- +77 IF $PIECE(MSPRES(9000037,AG("DA"),.63),U)=""
- WRITE "Date of transplant : _______________",!
- +78 IF $PIECE(MSPRES(9000037,AG("DA"),.63),U)'=""
- WRITE "Date of transplant : ",$PIECE(MSPRES(9000037,AG("DA"),.63),U),!
- +79 WRITE !,?5,"[ ] NO",!
- End DoDot:1
- +80 ;
- +81 WRITE !,?2,"3. Have you received maintenance dialysis treatments ? ",!
- +82 IF $PIECE(MSPRES(9000037,AG("DA"),.64),U)=""!($PIECE(MSPRES(9000037,AG("DA"),.64),U)="NO")
- Begin DoDot:1
- +83 WRITE !,?5,"[ ] YES Date dialysis began : _______________",!
- +84 WRITE !,?14,"If you participated in a self dialysis training"
- +85 WRITE !,?14,"program, provide date training started : _______________",!
- +86 IF $PIECE(MSPRES(9000037,AG("DA"),.64),U)=""
- WRITE !,?5,"[ ] NO",!
- +87 IF $PIECE(MSPRES(9000037,AG("DA"),.64),U)="NO"
- WRITE !,?5,"[X] NO",!
- End DoDot:1
- +88 IF $PIECE(MSPRES(9000037,AG("DA"),.64),U)="YES"
- Begin DoDot:1
- +89 WRITE !,?5,"[X] YES Date dialysis began : "
- +90 IF $PIECE(MSPRES(9000037,AG("DA"),.65),U)=""
- WRITE "_______________",!
- +91 IF $PIECE(MSPRES(9000037,AG("DA"),.65),U)'=""
- WRITE $PIECE(MSPRES(9000037,AG("DA"),.65),U),!
- +92 WRITE !,?14,"If you participated in a self dialysis training"
- +93 WRITE !,?14,"program, provide date training started : "
- +94 IF $PIECE(MSPRES(9000037,AG("DA"),.66),U)=""
- WRITE "_______________",!
- +95 IF $PIECE(MSPRES(9000037,AG("DA"),.66),U)'=""
- WRITE $PIECE(MSPRES(9000037,AG("DA"),.66),U),!
- +96 WRITE !,?5,"[ ] NO",!
- End DoDot:1
- +97 KILL AG("INSPTR"),AG("INSADDR"),AG("EMPPTR"),AG("EMPADDR"),AG("RELPTR")
- +98 QUIT
