AGMSP1.m

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