AGMSP3 ; IHS/ASDS/EFG - PRINT PAGE 3 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 III",!
I '$D(AG("MSPPRINT")) D BLANK1
I $D(AG("MSPPRINT")) D MAP1
W !!
W !,?50,"Continued on next page ==>"
W !,AGLINE("EQ")
W !,$P($G(^DIC(4,DUZ(2),0)),U),?73,"PAGE 3"
Q
BLANK1 ;THIS SECTION IS USED TO PRINT THE BLANK PAGE 3
W !,?2,"1. Are you entitled to Medicare based on : ",!
W !,?5,"[ ] Age - GO TO PART IV",!
W !,?5,"[ ] Disability _ GO TO PART V",!
W !,?5,"[ ] ESRD - GO TO PART VI",!
W !,"PART IV - Age",!
W !,?2,"1. Are you currently employed ? ",!
W !,?5,"[ ] YES",!
W !,?14,"Name and address of your employer : ",!
W !,?14,$E(AGLINE("_"),1,50),!
W !,?14,$E(AGLINE("_"),1,50),!
W !,?14,$E(AGLINE("_"),1,50),!
W !,?5,"[ ] NO Date of retirement : _______________",!
W !,?2,"2. Is your spouse currently employed ? ",!
W !,?5,"[ ] YES",!
W !,?14,"Name and address of spouse's 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 : _______________",!
W !?2,"If the patient answered 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."
Q
MAP1 ;THIS SECTION IS USED TO PRINT THE PATIENT'S DATA ON THE FORM
W !,?2,"1. Are you entitled to Medicare based on : ",!
I $P(MSPRES(9000037,AG("DA"),.25),U)="AGE" D
. W !,?5,"[X] Age - GO TO PART IV",!
E W !,?5,"[ ] Age - GO TO PART IV",!
I $P(MSPRES(9000037,AG("DA"),.25),U)="DISABILITY" D
. W !,?5,"[X] Disability _ GO TO PART V",!
E W !,?5,"[ ] Disability _ GO TO PART V",!
I $P(MSPRES(9000037,AG("DA"),.25),U)="ESRD" D
. W !,?5,"[X] ESRD - GO TO PART VI",!
E W !,?5,"[ ] ESRD - GO TO PART VI",!
;
W !,"PART IV - Age",!
W !,?2,"1. Are you currently employed ? ",!
I $P(MSPRES(9000037,AG("DA"),.26),U)=""!($P(MSPRES(9000037,AG("DA"),.26),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"),.26),U)="" W !,?5,"[ ] NO Date of retirement : _______________",!
. I $P(MSPRES(9000037,AG("DA"),.26),U)="NO" D
.. W !,?5,"[X] NO Date of retirement : "
.. W $P(MSPRES(9000037,AG("DA"),.28),U),!
I $P(MSPRES(9000037,AG("DA"),.26),U)="YES" D
. W !,?5,"[X] YES",!
. W !,?14,"Name and address of your employer : ",!
. S AG("EMPPTR")=$P($G(^AUPNMSP(AG("DA"),4)),U,2)
. I $G(AG("EMPPTR"))'="" D
.. S AG("EMPADDR")=$G(^AUTNEMPL(AG("EMPPTR"),0))
.. 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
.. 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
. 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 Date of retirement : _______________",!
;
W !,?2,"2. Is your spouse currently employed ? ",!
I $P(MSPRES(9000037,AG("DA"),.29),U)=""!($P(MSPRES(9000037,AG("DA"),.29),U)="NO") D
. W !,?5,"[ ] YES",!
. W !,?14,"Name and address of spouse'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"),.29),U)="" W !,?5,"[ ] NO Date of retirement : _______________",!
. I $P(MSPRES(9000037,AG("DA"),.29),U)="NO" W !,?5,"[X] NO Date of retirement : ",$P(MSPRES(9000037,AG("DA"),.32),U),!
I $P(MSPRES(9000037,AG("DA"),.29),U)="YES" D
. W !,?5,"[X] YES",!
. S AG("EMPPTR")=$P($G(^AUPNMSP(AG("DA"),4)),U,5)
. I $G(AG("EMPPTR"))'="" D
.. S AG("EMPADDR")=$G(^AUTNEMPL(AG("EMPPTR"),0))
.. 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
.. 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
. 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 Date of retirement : _______________",!
;
W !,?2,"3. Do you have group health plan (GHP) coverage based on your own, or a"
W !,?5,"spouse's current employment ? ",!
I $P(MSPRES(9000037,AG("DA"),.33),U)="" D
. W !,?5,"[ ] YES",!
. W !,?5,"[ ] NO",!
I $P(MSPRES(9000037,AG("DA"),.33),U)="YES" D
. W !,?5,"[X] YES",!
. W !,?5,"[ ] NO",!
I $P(MSPRES(9000037,AG("DA"),.33),U)="NO" D
. W !,?5,"[ ] YES",!
. W !,?5,"[X] NO",!
K AG("EMPPTR"),AG("EMPADDR")
Q
AGMSP3 ; IHS/ASDS/EFG - PRINT PAGE 3 OF MSP FORM ;
+1 ;;7.1;PATIENT REGISTRATION;;AUG 25,2005
+2 ;
+3 ;I AG("MSPPRINT") EXISTS, MAP DATA FROM AUPNMSP TO THE FORM
EN ;EP
+1 WRITE !,"PART III",!
+2 IF '$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($GET(^DIC(4,DUZ(2),0)),U),?73,"PAGE 3"
+8 QUIT
BLANK1 ;THIS SECTION IS USED TO PRINT THE BLANK PAGE 3
+1 WRITE !,?2,"1. Are you entitled to Medicare based on : ",!
+2 WRITE !,?5,"[ ] Age - GO TO PART IV",!
+3 WRITE !,?5,"[ ] Disability _ GO TO PART V",!
+4 WRITE !,?5,"[ ] ESRD - GO TO PART VI",!
+5 WRITE !,"PART IV - Age",!
+6 WRITE !,?2,"1. Are you currently employed ? ",!
+7 WRITE !,?5,"[ ] YES",!
+8 WRITE !,?14,"Name and address of your employer : ",!
+9 WRITE !,?14,$EXTRACT(AGLINE("_"),1,50),!
+10 WRITE !,?14,$EXTRACT(AGLINE("_"),1,50),!
+11 WRITE !,?14,$EXTRACT(AGLINE("_"),1,50),!
+12 WRITE !,?5,"[ ] NO Date of retirement : _______________",!
+13 WRITE !,?2,"2. Is your spouse currently employed ? ",!
+14 WRITE !,?5,"[ ] YES",!
+15 WRITE !,?14,"Name and address of spouse's employer : ",!
+16 WRITE !,?14,$EXTRACT(AGLINE("_"),1,50),!
+17 WRITE !,?14,$EXTRACT(AGLINE("_"),1,50),!
+18 WRITE !,?14,$EXTRACT(AGLINE("_"),1,50),!
+19 WRITE !,?5,"[ ] NO. Date of retirement : _______________",!
+20 WRITE !?2,"If the patient answered no to both questions 1 and 2, Medicare is primary"
+21 WRITE !?2,"unless the patient answered yes to questions in part I or II."
+22 WRITE !?2,"STOP. DO NOT PROCEED ANY FURTHER."
+23 QUIT
MAP1 ;THIS SECTION IS USED TO PRINT THE PATIENT'S DATA ON THE FORM
+1 WRITE !,?2,"1. Are you entitled to Medicare based on : ",!
+2 IF $PIECE(MSPRES(9000037,AG("DA"),.25),U)="AGE"
Begin DoDot:1
+3 WRITE !,?5,"[X] Age - GO TO PART IV",!
End DoDot:1
+4 IF '$TEST
WRITE !,?5,"[ ] Age - GO TO PART IV",!
+5 IF $PIECE(MSPRES(9000037,AG("DA"),.25),U)="DISABILITY"
Begin DoDot:1
+6 WRITE !,?5,"[X] Disability _ GO TO PART V",!
End DoDot:1
+7 IF '$TEST
WRITE !,?5,"[ ] Disability _ GO TO PART V",!
+8 IF $PIECE(MSPRES(9000037,AG("DA"),.25),U)="ESRD"
Begin DoDot:1
+9 WRITE !,?5,"[X] ESRD - GO TO PART VI",!
End DoDot:1
+10 IF '$TEST
WRITE !,?5,"[ ] ESRD - GO TO PART VI",!
+11 ;
+12 WRITE !,"PART IV - Age",!
+13 WRITE !,?2,"1. Are you currently employed ? ",!
+14 IF $PIECE(MSPRES(9000037,AG("DA"),.26),U)=""!($PIECE(MSPRES(9000037,AG("DA"),.26),U)="NO")
Begin DoDot:1
+15 WRITE !,?5,"[ ] YES",!
+16 WRITE !,?14,"Name and address of your employer : ",!
+17 WRITE !,?14,$EXTRACT(AGLINE("_"),1,50),!
+18 WRITE !,?14,$EXTRACT(AGLINE("_"),1,50),!
+19 WRITE !,?14,$EXTRACT(AGLINE("_"),1,50),!
+20 IF $PIECE(MSPRES(9000037,AG("DA"),.26),U)=""
WRITE !,?5,"[ ] NO Date of retirement : _______________",!
+21 IF $PIECE(MSPRES(9000037,AG("DA"),.26),U)="NO"
Begin DoDot:2
+22 WRITE !,?5,"[X] NO Date of retirement : "
+23 WRITE $PIECE(MSPRES(9000037,AG("DA"),.28),U),!
End DoDot:2
End DoDot:1
+24 IF $PIECE(MSPRES(9000037,AG("DA"),.26),U)="YES"
Begin DoDot:1
+25 WRITE !,?5,"[X] YES",!
+26 WRITE !,?14,"Name and address of your employer : ",!
+27 SET AG("EMPPTR")=$PIECE($GET(^AUPNMSP(AG("DA"),4)),U,2)
+28 IF $GET(AG("EMPPTR"))'=""
Begin DoDot:2
+29 SET AG("EMPADDR")=$GET(^AUTNEMPL(AG("EMPPTR"),0))
+30 ;EMPLOYER
WRITE !,?14,$PIECE(AG("EMPADDR"),U),!
+31 ;EMPLOYER STREET
WRITE !,?14,$PIECE(AG("EMPADDR"),U,2),!
+32 ;EMPLOYER CITY
WRITE !,?14,$PIECE(AG("EMPADDR"),U,3)
+33 IF $PIECE(AG("EMPADDR"),U,4)'=""
Begin DoDot:3
+34 ;EMPLOYER STATE
WRITE ", ",$PIECE($GET(^DIC(5,$PIECE(AG("EMPADDR"),U,4),0)),U,2)
End DoDot:3
+35 ;EMPLOYER ZIP
WRITE ", ",$PIECE(AG("EMPADDR"),U,5),!
End DoDot:2
+36 IF $GET(AG("EMPPTR"))=""
Begin DoDot:2
+37 WRITE !,?14,$EXTRACT(AGLINE("_"),1,50),!
+38 WRITE !,?14,$EXTRACT(AGLINE("_"),1,50),!
+39 WRITE !,?14,$EXTRACT(AGLINE("_"),1,50),!
End DoDot:2
+40 WRITE !,?5,"[ ] NO Date of retirement : _______________",!
End DoDot:1
+41 ;
+42 WRITE !,?2,"2. Is your spouse currently employed ? ",!
+43 IF $PIECE(MSPRES(9000037,AG("DA"),.29),U)=""!($PIECE(MSPRES(9000037,AG("DA"),.29),U)="NO")
Begin DoDot:1
+44 WRITE !,?5,"[ ] YES",!
+45 WRITE !,?14,"Name and address of spouse's 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"),.29),U)=""
WRITE !,?5,"[ ] NO Date of retirement : _______________",!
+50 IF $PIECE(MSPRES(9000037,AG("DA"),.29),U)="NO"
WRITE !,?5,"[X] NO Date of retirement : ",$PIECE(MSPRES(9000037,AG("DA"),.32),U),!
End DoDot:1
+51 IF $PIECE(MSPRES(9000037,AG("DA"),.29),U)="YES"
Begin DoDot:1
+52 WRITE !,?5,"[X] YES",!
+53 SET AG("EMPPTR")=$PIECE($GET(^AUPNMSP(AG("DA"),4)),U,5)
+54 IF $GET(AG("EMPPTR"))'=""
Begin DoDot:2
+55 SET AG("EMPADDR")=$GET(^AUTNEMPL(AG("EMPPTR"),0))
+56 ;EMPLOYER
WRITE !,?14,$PIECE(AG("EMPADDR"),U),!
+57 ;EMPLOYER STREET
WRITE !,?14,$PIECE(AG("EMPADDR"),U,2),!
+58 ;EMPLOYER CITY
WRITE !,?14,$PIECE(AG("EMPADDR"),U,3)
+59 IF $PIECE(AG("EMPADDR"),U,4)'=""
Begin DoDot:3
+60 ;EMPLOYER STATE
WRITE ", ",$PIECE($GET(^DIC(5,$PIECE(AG("EMPADDR"),U,4),0)),U,2)
End DoDot:3
+61 ;EMPLOYER ZIP
WRITE ", ",$PIECE(AG("EMPADDR"),U,5),!
End DoDot:2
+62 IF $GET(AG("EMPPTR"))=""
Begin DoDot:2
+63 WRITE !,?14,$EXTRACT(AGLINE("_"),1,50),!
+64 WRITE !,?14,$EXTRACT(AGLINE("_"),1,50),!
+65 WRITE !,?14,$EXTRACT(AGLINE("_"),1,50),!
End DoDot:2
+66 WRITE !,?5,"[ ] NO Date of retirement : _______________",!
End DoDot:1
+67 ;
+68 WRITE !,?2,"3. Do you have group health plan (GHP) coverage based on your own, or a"
+69 WRITE !,?5,"spouse's current employment ? ",!
+70 IF $PIECE(MSPRES(9000037,AG("DA"),.33),U)=""
Begin DoDot:1
+71 WRITE !,?5,"[ ] YES",!
+72 WRITE !,?5,"[ ] NO",!
End DoDot:1
+73 IF $PIECE(MSPRES(9000037,AG("DA"),.33),U)="YES"
Begin DoDot:1
+74 WRITE !,?5,"[X] YES",!
+75 WRITE !,?5,"[ ] NO",!
End DoDot:1
+76 IF $PIECE(MSPRES(9000037,AG("DA"),.33),U)="NO"
Begin DoDot:1
+77 WRITE !,?5,"[ ] YES",!
+78 WRITE !,?5,"[X] NO",!
End DoDot:1
+79 KILL AG("EMPPTR"),AG("EMPADDR")
+80 QUIT
