AGMSP2 ; IHS/ASDS/EFG - PRINT PAGE 2 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 II",!
I '$D(AG("MSPPRINT")) D BLANK1
I $D(AG("MSPPRINT")) D MAP1
W !
W !,?50,"Continued on next page ==>"
W !,AGLINE("EQ")
W !,$P($G(^DIC(4,DUZ(2),0)),U),?73,"PAGE 2"
Q
BLANK1 ;THIS SECTION IS USED TO PRINT THE BLANK PAGE 2
W !,?2,"1. Was the illness/injury due to a non-work-related accident ? ",!
W !,?5,"[ ] YES Date of accident : _______________",!
W !,?5,"[ ] NO - GO TO PART III",!
W !,?2,"2. What type of accident caused the illness/injury ? ",!
W !,?5,"[ ] Automobile",!
W !,?5,"[ ] Non-Automobile",!
W !,?14,"Name and address of no-fault or liability insurer : ",!
W !,?14,$E(AGLINE("_"),1,50),!
W !,?14,$E(AGLINE("_"),1,50),!
W !,?14,$E(AGLINE("_"),1,50),!
W !,?5,"Insurance claim number : _______________",!
W !,"No-fault insurer is primary payer only for those claims related to the accident."
W !,"GO TO PART III.",!
W !,?5,"[ ] Other",!
W !?2,"3. Was another party responsible for this accident ? ",!
W !,?5,"[ ] YES",!
W !,?14,"Name and address of any liability insurer : ",!
W !,?14,$E(AGLINE("_"),1,50),!
W !,?14,$E(AGLINE("_"),1,50),!
W !,?14,$E(AGLINE("_"),1,50),!
W !,?14,"Insurance claim number : _______________",!
W !?2,"The liability insurer is primary only for those claims related to"
W !?2,"the accident. GO TO PART III.",!
W !,?5,"[ ] NO - GO TO PART III",!
Q
MAP1 ;THIS SECTION IS USED TO PRINT THE PATIENT'S DATA ON THE FORM
W !,?2,"1. Was the illness/injury due to a non-work related accident ? ",!
I $P(MSPRES(9000037,AG("DA"),.16),U)="" D
. W !,?5,"[ ] YES Date of accident : _______________",!
. W !,?5,"[ ] NO - GO TO PART III",!
I $P(MSPRES(9000037,AG("DA"),.16),U)="NO" D
. W !,?5,"[ ] YES Date of accident : _______________",!
. W !,?5,"[X] NO - GO TO PART III",!
I $P(MSPRES(9000037,AG("DA"),.16),U)="YES" D
. W !,?5,"[X] YES Date of accident : "
. W $P(MSPRES(9000037,AG("DA"),.17),U)
. W !,?5,"[ ] NO - GO TO PART III",!
;
W !,?2,"2. What type of accident caused the illness/injury ? ",!
I $P(MSPRES(9000037,AG("DA"),.18),U)=""!($P(MSPRES(9000037,AG("DA"),.18),U)="OTHER") D
. W !,?5,"[ ] Automobile",!
. W !,?5,"[ ] Non-Automobile",!
. W !,?5,"Name and address of no-fault or liability insurer : ",!
. W !,?5,$E(AGLINE("_"),1,50),!
. W !,?5,$E(AGLINE("_"),1,50),!
. W !,?5,$E(AGLINE("_"),1,50),!
. W !,?5,"Insurance claim number : _______________",!
. I $P(MSPRES(9000037,AG("DA"),.18),U)="" W !,?5,"[ ] Other",!
. I $P(MSPRES(9000037,AG("DA"),.18),U)="OTHER" W !,?5,"[X] Other",!
I $P(MSPRES(9000037,AG("DA"),.18),U)="AUTOMOBILE"!($P(MSPRES(9000037,AG("DA"),.18),U)="NON-AUTOMOBILE") D
. I $P(MSPRES(9000037,AG("DA"),.18),U)="AUTOMOBILE" D
.. W !,?5,"[X] Automobile",!
.. W !,?5,"[ ] Non-Automobile",!
. I $P(MSPRES(9000037,AG("DA"),.18),U)="NON-AUTOMOBILE" D
.. W !,?5,"[ ] Automobile",!
.. W !,?5,"[X] Non-Automobile",!
. W !,?5,"Name and address of no-fault or liability insurer : ",!
. I $P(MSPRES(9000037,AG("DA"),.19),U)="" D
.. W !,?5,$E(AGLINE("_"),1,50),!
.. W !,?5,$E(AGLINE("_"),1,50),!
.. W !,?5,$E(AGLINE("_"),1,50),!
. I $P(MSPRES(9000037,AG("DA"),.19),U)'="" D
.. S AG("INSPTR")=$P($G(^AUPNMSP(AG("DA"),2)),U,4)
.. S AG("INSADDR")=$G(^AUTNINS(AG("INSPTR"),0))
.. W !,?5,$P(AG("INSADDR"),U),! ;INSURER NAME
.. W !,?5,$P(AG("INSADDR"),U,2),! ;INSURER STREET
.. W !,?5,$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"),.21),U)="" D
.. W !,?5,"Insurance claim number : _______________",!
. I $P(MSPRES(9000037,AG("DA"),.21),U)'="" D
.. W !,?5,"Insurance claim number : ",$P(MSPRES(9000037,AG("DA"),.21),U),!
. W !,?5,"[ ] Other",!
;
W !?2,"3. Was another party responsible for this accident ? ",!
I $P(MSPRES(9000037,AG("DA"),.22),U)=""!($P(MSPRES(9000037,AG("DA"),.22),U)="NO") D
. W !,?5,"[ ] YES",!
. W !,?14,"Name and address of any liability insurer : ",!
. W !,?14,$E(AGLINE("_"),1,50),!
. W !,?14,$E(AGLINE("_"),1,50),!
. W !,?14,$E(AGLINE("_"),1,50),!
. W !,?14,"Insurance claim number : _______________",!
. I $P(MSPRES(9000037,AG("DA"),.22),U)="" W !,?5,"[ ] NO - GO TO PART III",!
. I $P(MSPRES(9000037,AG("DA"),.22),U)="NO" W !,?5,"[X] NO - GO TO PART III",!
I $P(MSPRES(9000037,AG("DA"),.22),U)="YES" D
. W !,?5,"[X] YES",!
. W !,?14,"Name and address of any liability insurer : ",!
. I $P(MSPRES(9000037,AG("DA"),.23),U)="" D
.. W !,?14,$E(AGLINE("_"),1,50),!
.. W !,?14,$E(AGLINE("_"),1,50),!
.. W !,?14,$E(AGLINE("_"),1,50),!
. I $P(MSPRES(9000037,AG("DA"),.23),U)'="" D
.. S AG("INSPTR")=$P($G(^AUPNMSP(AG("DA"),2)),U,7)
.. S AG("INSADDR")=$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"),.24),U)="" D
.. W !,?5,"Insurance claim number : _______________",!
. I $P(MSPRES(9000037,AG("DA"),.24),U)'="" D
.. W !,?5,"Insurance claim number : ",$P(MSPRES(9000037,AG("DA"),.24),U),!
. W !,?5,"[ ] NO - GO TO PART III",!
K AG("INSPTR"),AG("INSADDR")
Q
AGMSP2 ; IHS/ASDS/EFG - PRINT PAGE 2 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 II",!
+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($GET(^DIC(4,DUZ(2),0)),U),?73,"PAGE 2"
+8 QUIT
BLANK1 ;THIS SECTION IS USED TO PRINT THE BLANK PAGE 2
+1 WRITE !,?2,"1. Was the illness/injury due to a non-work-related accident ? ",!
+2 WRITE !,?5,"[ ] YES Date of accident : _______________",!
+3 WRITE !,?5,"[ ] NO - GO TO PART III",!
+4 WRITE !,?2,"2. What type of accident caused the illness/injury ? ",!
+5 WRITE !,?5,"[ ] Automobile",!
+6 WRITE !,?5,"[ ] Non-Automobile",!
+7 WRITE !,?14,"Name and address of no-fault or liability insurer : ",!
+8 WRITE !,?14,$EXTRACT(AGLINE("_"),1,50),!
+9 WRITE !,?14,$EXTRACT(AGLINE("_"),1,50),!
+10 WRITE !,?14,$EXTRACT(AGLINE("_"),1,50),!
+11 WRITE !,?5,"Insurance claim number : _______________",!
+12 WRITE !,"No-fault insurer is primary payer only for those claims related to the accident."
+13 WRITE !,"GO TO PART III.",!
+14 WRITE !,?5,"[ ] Other",!
+15 WRITE !?2,"3. Was another party responsible for this accident ? ",!
+16 WRITE !,?5,"[ ] YES",!
+17 WRITE !,?14,"Name and address of any liability insurer : ",!
+18 WRITE !,?14,$EXTRACT(AGLINE("_"),1,50),!
+19 WRITE !,?14,$EXTRACT(AGLINE("_"),1,50),!
+20 WRITE !,?14,$EXTRACT(AGLINE("_"),1,50),!
+21 WRITE !,?14,"Insurance claim number : _______________",!
+22 WRITE !?2,"The liability insurer is primary only for those claims related to"
+23 WRITE !?2,"the accident. GO TO PART III.",!
+24 WRITE !,?5,"[ ] NO - GO TO PART III",!
+25 QUIT
MAP1 ;THIS SECTION IS USED TO PRINT THE PATIENT'S DATA ON THE FORM
+1 WRITE !,?2,"1. Was the illness/injury due to a non-work related accident ? ",!
+2 IF $PIECE(MSPRES(9000037,AG("DA"),.16),U)=""
Begin DoDot:1
+3 WRITE !,?5,"[ ] YES Date of accident : _______________",!
+4 WRITE !,?5,"[ ] NO - GO TO PART III",!
End DoDot:1
+5 IF $PIECE(MSPRES(9000037,AG("DA"),.16),U)="NO"
Begin DoDot:1
+6 WRITE !,?5,"[ ] YES Date of accident : _______________",!
+7 WRITE !,?5,"[X] NO - GO TO PART III",!
End DoDot:1
+8 IF $PIECE(MSPRES(9000037,AG("DA"),.16),U)="YES"
Begin DoDot:1
+9 WRITE !,?5,"[X] YES Date of accident : "
+10 WRITE $PIECE(MSPRES(9000037,AG("DA"),.17),U)
+11 WRITE !,?5,"[ ] NO - GO TO PART III",!
End DoDot:1
+12 ;
+13 WRITE !,?2,"2. What type of accident caused the illness/injury ? ",!
+14 IF $PIECE(MSPRES(9000037,AG("DA"),.18),U)=""!($PIECE(MSPRES(9000037,AG("DA"),.18),U)="OTHER")
Begin DoDot:1
+15 WRITE !,?5,"[ ] Automobile",!
+16 WRITE !,?5,"[ ] Non-Automobile",!
+17 WRITE !,?5,"Name and address of no-fault or liability insurer : ",!
+18 WRITE !,?5,$EXTRACT(AGLINE("_"),1,50),!
+19 WRITE !,?5,$EXTRACT(AGLINE("_"),1,50),!
+20 WRITE !,?5,$EXTRACT(AGLINE("_"),1,50),!
+21 WRITE !,?5,"Insurance claim number : _______________",!
+22 IF $PIECE(MSPRES(9000037,AG("DA"),.18),U)=""
WRITE !,?5,"[ ] Other",!
+23 IF $PIECE(MSPRES(9000037,AG("DA"),.18),U)="OTHER"
WRITE !,?5,"[X] Other",!
End DoDot:1
+24 IF $PIECE(MSPRES(9000037,AG("DA"),.18),U)="AUTOMOBILE"!($PIECE(MSPRES(9000037,AG("DA"),.18),U)="NON-AUTOMOBILE")
Begin DoDot:1
+25 IF $PIECE(MSPRES(9000037,AG("DA"),.18),U)="AUTOMOBILE"
Begin DoDot:2
+26 WRITE !,?5,"[X] Automobile",!
+27 WRITE !,?5,"[ ] Non-Automobile",!
End DoDot:2
+28 IF $PIECE(MSPRES(9000037,AG("DA"),.18),U)="NON-AUTOMOBILE"
Begin DoDot:2
+29 WRITE !,?5,"[ ] Automobile",!
+30 WRITE !,?5,"[X] Non-Automobile",!
End DoDot:2
+31 WRITE !,?5,"Name and address of no-fault or liability insurer : ",!
+32 IF $PIECE(MSPRES(9000037,AG("DA"),.19),U)=""
Begin DoDot:2
+33 WRITE !,?5,$EXTRACT(AGLINE("_"),1,50),!
+34 WRITE !,?5,$EXTRACT(AGLINE("_"),1,50),!
+35 WRITE !,?5,$EXTRACT(AGLINE("_"),1,50),!
End DoDot:2
+36 IF $PIECE(MSPRES(9000037,AG("DA"),.19),U)'=""
Begin DoDot:2
+37 SET AG("INSPTR")=$PIECE($GET(^AUPNMSP(AG("DA"),2)),U,4)
+38 SET AG("INSADDR")=$GET(^AUTNINS(AG("INSPTR"),0))
+39 ;INSURER NAME
WRITE !,?5,$PIECE(AG("INSADDR"),U),!
+40 ;INSURER STREET
WRITE !,?5,$PIECE(AG("INSADDR"),U,2),!
+41 ;INSURER CITY
WRITE !,?5,$PIECE(AG("INSADDR"),U,3)
+42 IF $PIECE(AG("INSADDR"),U,4)'=""
Begin DoDot:3
+43 ;INSURER STATE
WRITE ", ",$PIECE($GET(^DIC(5,$PIECE(AG("INSADDR"),U,4),0)),U,2)
End DoDot:3
+44 ;INSURER ZIP
WRITE ", ",$PIECE(AG("INSADDR"),U,5),!
End DoDot:2
+45 IF $PIECE(MSPRES(9000037,AG("DA"),.21),U)=""
Begin DoDot:2
+46 WRITE !,?5,"Insurance claim number : _______________",!
End DoDot:2
+47 IF $PIECE(MSPRES(9000037,AG("DA"),.21),U)'=""
Begin DoDot:2
+48 WRITE !,?5,"Insurance claim number : ",$PIECE(MSPRES(9000037,AG("DA"),.21),U),!
End DoDot:2
+49 WRITE !,?5,"[ ] Other",!
End DoDot:1
+50 ;
+51 WRITE !?2,"3. Was another party responsible for this accident ? ",!
+52 IF $PIECE(MSPRES(9000037,AG("DA"),.22),U)=""!($PIECE(MSPRES(9000037,AG("DA"),.22),U)="NO")
Begin DoDot:1
+53 WRITE !,?5,"[ ] YES",!
+54 WRITE !,?14,"Name and address of any liability insurer : ",!
+55 WRITE !,?14,$EXTRACT(AGLINE("_"),1,50),!
+56 WRITE !,?14,$EXTRACT(AGLINE("_"),1,50),!
+57 WRITE !,?14,$EXTRACT(AGLINE("_"),1,50),!
+58 WRITE !,?14,"Insurance claim number : _______________",!
+59 IF $PIECE(MSPRES(9000037,AG("DA"),.22),U)=""
WRITE !,?5,"[ ] NO - GO TO PART III",!
+60 IF $PIECE(MSPRES(9000037,AG("DA"),.22),U)="NO"
WRITE !,?5,"[X] NO - GO TO PART III",!
End DoDot:1
+61 IF $PIECE(MSPRES(9000037,AG("DA"),.22),U)="YES"
Begin DoDot:1
+62 WRITE !,?5,"[X] YES",!
+63 WRITE !,?14,"Name and address of any liability insurer : ",!
+64 IF $PIECE(MSPRES(9000037,AG("DA"),.23),U)=""
Begin DoDot:2
+65 WRITE !,?14,$EXTRACT(AGLINE("_"),1,50),!
+66 WRITE !,?14,$EXTRACT(AGLINE("_"),1,50),!
+67 WRITE !,?14,$EXTRACT(AGLINE("_"),1,50),!
End DoDot:2
+68 IF $PIECE(MSPRES(9000037,AG("DA"),.23),U)'=""
Begin DoDot:2
+69 SET AG("INSPTR")=$PIECE($GET(^AUPNMSP(AG("DA"),2)),U,7)
+70 SET AG("INSADDR")=$GET(^AUTNINS(AG("INSPTR"),0))
+71 ;INSURER NAME
WRITE !,?14,$PIECE(AG("INSADDR"),U),!
+72 ;INSURER STREET
WRITE !,?14,$PIECE(AG("INSADDR"),U,2),!
+73 ;INSURER CITY
WRITE !,?14,$PIECE(AG("INSADDR"),U,3)
+74 IF $PIECE(AG("INSADDR"),U,4)'=""
Begin DoDot:3
+75 ;INSURER STATE
WRITE ", ",$PIECE($GET(^DIC(5,$PIECE(AG("INSADDR"),U,4)),0),U,2)
End DoDot:3
+76 ;INSURER ZIP
WRITE ", ",$PIECE(AG("INSADDR"),U,5),!
End DoDot:2
+77 IF $PIECE(MSPRES(9000037,AG("DA"),.24),U)=""
Begin DoDot:2
+78 WRITE !,?5,"Insurance claim number : _______________",!
End DoDot:2
+79 IF $PIECE(MSPRES(9000037,AG("DA"),.24),U)'=""
Begin DoDot:2
+80 WRITE !,?5,"Insurance claim number : ",$PIECE(MSPRES(9000037,AG("DA"),.24),U),!
End DoDot:2
+81 WRITE !,?5,"[ ] NO - GO TO PART III",!
End DoDot:1
+82 KILL AG("INSPTR"),AG("INSADDR")
+83 QUIT
