AGMSP4 ; IHS/ASDS/EFG - PRINT PAGE 4 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 IV - Age (con't)",!
I '$D(AG("MSPPRINT")) D BLANK1
I $D(AG("MSPPRINT")) D MAP1
W !
W !,?50,"Continued on next page ==>"
W !,AGLINE("EQ")
W !,$P($G(^DIC(4,DUZ(2),0)),U),?73,"PAGE 4"
Q
BLANK1 ;THIS SECTION IS USED TO PRINT THE BLANK PAGE 4
W !,?2,"3. Do you have group health plan (GHP) coverage based on your own, or a"
W !,?5,"spouse's current employment ? ",!
W !,?5,"[ ] YES",!
W !,?5,"[ ] NO. STOP. Medicare is primary payer unless the patient answered yes"
W !?19,"to the questions in part I or II.",!
W !,?2,"4. Does the employer that sponsors your GHP employ 20 or more employees ? ",!
W !,?5,"[ ] YES. STOP. The GHP is primary. Obtain the following information:"
W !,?14,"Name and address of GHP : ",!
W !,?14,$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 payer unless the patient answered"
W !,!?20,"yes to questions in part I or II.",!
W !,"PART V - Disability",!
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 : _______________",!
Q
MAP1 ;THIS SECTION IS USED TO PRINT THE PATIENT'S DATA ON THE FORM
W !,?2,"4. Does the employer that sponsors your GHP employ 20 or more employees ? ",!
I $P(MSPRES(9000037,AG("DA"),.34),U)=""!($P(MSPRES(9000037,AG("DA"),.34),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"),.34),U)="" W !,?5,"[ ] NO",!
. I $P(MSPRES(9000037,AG("DA"),.34),U)="NO" W !,?5,"[X] NO",!
I $P(MSPRES(9000037,AG("DA"),.34),U)="YES" D
. W !,?5,"[X] YES",!
. W !,?14,"Name and address of GHP : ",!
. I $P(MSPRES(9000037,AG("DA"),.35),U)="" D
.. W !,?14,$E(AGLINE("_"),1,50),!
.. W !,?14,$E(AGLINE("_"),1,50),!
.. W !,?14,$E(AGLINE("_"),1,50),!
. I $P(MSPRES(9000037,AG("DA"),.35),U)'="" D
.. S AG("INSPTR")=$P($G(^AUPNMSP(AG("DA"),4)),U,9)
.. S AG("INSADDR")=$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"),.36),U)="" D
.. W !!,?14,"Policy Identification Number : _______________",!
. I $P(MSPRES(9000037,AG("DA"),.36),U)'="" D
.. W !!,?14,"Policy Identification Number : ",$P(MSPRES(9000037,AG("DA"),.36),U),!
. I $P(MSPRES(9000037,AG("DA"),.37),U)="" D
.. W !,?14,"Group Identification Number : _______________",!
. I $P(MSPRES(9000037,AG("DA"),.37),U)'="" D
.. W !,?14,"Group Identification Number : ",$P(MSPRES(9000037,AG("DA"),.37),U),!
. I $P(MSPRES(9000037,AG("DA"),.38),U)="" D
.. W !,?14,"Name of Policy Holder : ______________________",!
. I $P(MSPRES(9000037,AG("DA"),.38),U)'="" D
.. W !,?14,"Name of Policy Holder : ",$P(MSPRES(9000037,AG("DA"),.38),U),!
. I $P(MSPRES(9000037,AG("DA"),.39),U)="" D
.. W !,?14,"Relationship to Patient : ____________________",!
. I $P(MSPRES(9000037,AG("DA"),.39),U)'="" D
.. S AG("RELPTR")=$P($G(^AUPNMSP(AG("DA"),4)),U,13)
.. W !,?14,"Relationship to Patient : ",$P($G(^AUTTRLSH(AG("RELPTR"),0)),U),!
. W !,?5,"[ ] NO",!
;
W !,"PART V - Disability",!
W !,?2,"1. Are you currently employed ? ",!
I $P(MSPRES(9000037,AG("DA"),.41),U)=""!($P(MSPRES(9000037,AG("DA"),.41),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"),.41),U)="" W !,?5,"[ ] NO Date of retirement : _______________",!
. I $P(MSPRES(9000037,AG("DA"),.41),U)="NO" D
.. W !,?5,"[X] NO Date of retirement : "
.. W $P(MSPRES(9000037,AG("DA"),.43),U),!
I $P(MSPRES(9000037,AG("DA"),.41),U)="YES" D
. S AG("EMPPTR")=$P($G(^AUPNMSP(AG("DA"),5)),U,2)
. I $G(AG("EMPPTR"))'="" D
.. S AG("EMPADDR")=$G(^AUTNEMPL(AG("EMPPTR"),0))
.. W !,?5,"[X] YES",!
.. W !,?14,"Name and address of your 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 Date of retirement : _______________",!
. I $G(AG("EMPPTR"))="" D
.. W !,?5,"[X] YES",!
.. W !,?14,$E(AGLINE("_"),1,50),!
.. W !,?14,$E(AGLINE("_"),1,50),!
.. W !,?14,$E(AGLINE("_"),1,50),!
.. W !,?5,"[ ] NO Date of retirement : _______________",!
K AG("INSPTR"),AG("INSADDR"),AG("EMPPTR"),AG("EMPADDR"),AG("RELPTR")
Q
AGMSP4 ; IHS/ASDS/EFG - PRINT PAGE 4 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 IV - Age (con't)",!
+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($GET(^DIC(4,DUZ(2),0)),U),?73,"PAGE 4"
+8 QUIT
BLANK1 ;THIS SECTION IS USED TO PRINT THE BLANK PAGE 4
+1 WRITE !,?2,"3. Do you have group health plan (GHP) coverage based on your own, or a"
+2 WRITE !,?5,"spouse's current employment ? ",!
+3 WRITE !,?5,"[ ] YES",!
+4 WRITE !,?5,"[ ] NO. STOP. Medicare is primary payer unless the patient answered yes"
+5 WRITE !?19,"to the questions in part I or II.",!
+6 WRITE !,?2,"4. Does the employer that sponsors your GHP employ 20 or more employees ? ",!
+7 WRITE !,?5,"[ ] YES. STOP. The GHP is primary. Obtain the following information:"
+8 WRITE !,?14,"Name and address of GHP : ",!
+9 WRITE !,?14,$EXTRACT(AGLINE("_"),1,50),!
+10 WRITE !,?14,$EXTRACT(AGLINE("_"),1,50),!
+11 WRITE !,?14,$EXTRACT(AGLINE("_"),1,50),!
+12 WRITE !,?14,"Policy Identification Number : _______________",!
+13 WRITE !,?14,"Group Identification Number : _______________",!
+14 WRITE !,?14,"Name of Policy Holder : ______________________",!
+15 WRITE !,?14,"Relationship to Patient : ____________________",!
+16 WRITE !,?5,"[ ] NO. STOP. Medicare is primary payer unless the patient answered"
+17 WRITE !,!?20,"yes to questions in part I or II.",!
+18 WRITE !,"PART V - Disability",!
+19 WRITE !,?2,"1. Are you currently employed ? ",!
+20 WRITE !,?5,"[ ] YES"
+21 WRITE !,?14,"Name and address of your employer : ",!
+22 WRITE !,?14,$EXTRACT(AGLINE("_"),1,50),!
+23 WRITE !,?14,$EXTRACT(AGLINE("_"),1,50),!
+24 WRITE !,?14,$EXTRACT(AGLINE("_"),1,50),!
+25 WRITE !,?5,"[ ] NO Date of retirement : _______________",!
+26 QUIT
MAP1 ;THIS SECTION IS USED TO PRINT THE PATIENT'S DATA ON THE FORM
+1 WRITE !,?2,"4. Does the employer that sponsors your GHP employ 20 or more employees ? ",!
+2 IF $PIECE(MSPRES(9000037,AG("DA"),.34),U)=""!($PIECE(MSPRES(9000037,AG("DA"),.34),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 IF $PIECE(MSPRES(9000037,AG("DA"),.34),U)=""
WRITE !,?5,"[ ] NO",!
+13 IF $PIECE(MSPRES(9000037,AG("DA"),.34),U)="NO"
WRITE !,?5,"[X] NO",!
End DoDot:1
+14 IF $PIECE(MSPRES(9000037,AG("DA"),.34),U)="YES"
Begin DoDot:1
+15 WRITE !,?5,"[X] YES",!
+16 WRITE !,?14,"Name and address of GHP : ",!
+17 IF $PIECE(MSPRES(9000037,AG("DA"),.35),U)=""
Begin DoDot:2
+18 WRITE !,?14,$EXTRACT(AGLINE("_"),1,50),!
+19 WRITE !,?14,$EXTRACT(AGLINE("_"),1,50),!
+20 WRITE !,?14,$EXTRACT(AGLINE("_"),1,50),!
End DoDot:2
+21 IF $PIECE(MSPRES(9000037,AG("DA"),.35),U)'=""
Begin DoDot:2
+22 SET AG("INSPTR")=$PIECE($GET(^AUPNMSP(AG("DA"),4)),U,9)
+23 SET AG("INSADDR")=$GET(^AUTNINS(AG("INSPTR"),0))
+24 ;INSURER NAME
WRITE !,?14,$PIECE(AG("INSADDR"),U),!
+25 ;INSURER STREET
WRITE !,?14,$PIECE(AG("INSADDR"),U,2),!
+26 ;INSURER CITY
WRITE !,?14,$PIECE(AG("INSADDR"),U,3)
+27 IF $PIECE(AG("INSADDR"),U,4)'=""
Begin DoDot:3
+28 ;INSURER STATE
WRITE ", ",$PIECE($GET(^DIC(5,$PIECE(AG("INSADDR"),U,4),0)),U,2)
End DoDot:3
+29 ;INSURER ZIP
WRITE ", ",$PIECE(AG("INSADDR"),U,5),!
End DoDot:2
+30 IF $PIECE(MSPRES(9000037,AG("DA"),.36),U)=""
Begin DoDot:2
+31 WRITE !!,?14,"Policy Identification Number : _______________",!
End DoDot:2
+32 IF $PIECE(MSPRES(9000037,AG("DA"),.36),U)'=""
Begin DoDot:2
+33 WRITE !!,?14,"Policy Identification Number : ",$PIECE(MSPRES(9000037,AG("DA"),.36),U),!
End DoDot:2
+34 IF $PIECE(MSPRES(9000037,AG("DA"),.37),U)=""
Begin DoDot:2
+35 WRITE !,?14,"Group Identification Number : _______________",!
End DoDot:2
+36 IF $PIECE(MSPRES(9000037,AG("DA"),.37),U)'=""
Begin DoDot:2
+37 WRITE !,?14,"Group Identification Number : ",$PIECE(MSPRES(9000037,AG("DA"),.37),U),!
End DoDot:2
+38 IF $PIECE(MSPRES(9000037,AG("DA"),.38),U)=""
Begin DoDot:2
+39 WRITE !,?14,"Name of Policy Holder : ______________________",!
End DoDot:2
+40 IF $PIECE(MSPRES(9000037,AG("DA"),.38),U)'=""
Begin DoDot:2
+41 WRITE !,?14,"Name of Policy Holder : ",$PIECE(MSPRES(9000037,AG("DA"),.38),U),!
End DoDot:2
+42 IF $PIECE(MSPRES(9000037,AG("DA"),.39),U)=""
Begin DoDot:2
+43 WRITE !,?14,"Relationship to Patient : ____________________",!
End DoDot:2
+44 IF $PIECE(MSPRES(9000037,AG("DA"),.39),U)'=""
Begin DoDot:2
+45 SET AG("RELPTR")=$PIECE($GET(^AUPNMSP(AG("DA"),4)),U,13)
+46 WRITE !,?14,"Relationship to Patient : ",$PIECE($GET(^AUTTRLSH(AG("RELPTR"),0)),U),!
End DoDot:2
+47 WRITE !,?5,"[ ] NO",!
End DoDot:1
+48 ;
+49 WRITE !,"PART V - Disability",!
+50 WRITE !,?2,"1. Are you currently employed ? ",!
+51 IF $PIECE(MSPRES(9000037,AG("DA"),.41),U)=""!($PIECE(MSPRES(9000037,AG("DA"),.41),U)="NO")
Begin DoDot:1
+52 WRITE !,?5,"[ ] YES",!
+53 WRITE !,?14,"Name and address of your employer : ",!
+54 WRITE !,?14,$EXTRACT(AGLINE("_"),1,50),!
+55 WRITE !,?14,$EXTRACT(AGLINE("_"),1,50),!
+56 WRITE !,?14,$EXTRACT(AGLINE("_"),1,50),!
+57 IF $PIECE(MSPRES(9000037,AG("DA"),.41),U)=""
WRITE !,?5,"[ ] NO Date of retirement : _______________",!
+58 IF $PIECE(MSPRES(9000037,AG("DA"),.41),U)="NO"
Begin DoDot:2
+59 WRITE !,?5,"[X] NO Date of retirement : "
+60 WRITE $PIECE(MSPRES(9000037,AG("DA"),.43),U),!
End DoDot:2
End DoDot:1
+61 IF $PIECE(MSPRES(9000037,AG("DA"),.41),U)="YES"
Begin DoDot:1
+62 SET AG("EMPPTR")=$PIECE($GET(^AUPNMSP(AG("DA"),5)),U,2)
+63 IF $GET(AG("EMPPTR"))'=""
Begin DoDot:2
+64 SET AG("EMPADDR")=$GET(^AUTNEMPL(AG("EMPPTR"),0))
+65 WRITE !,?5,"[X] YES",!
+66 WRITE !,?14,"Name and address of your employer : ",!
+67 ;EMPLOYER NAME
WRITE !,?14,$PIECE(AG("EMPADDR"),U),!
+68 ;EMPLOYER STREET
WRITE !,?14,$PIECE(AG("EMPADDR"),U,2),!
+69 ;EMPLOYER CITY
WRITE !,?14,$PIECE(AG("EMPADDR"),U,3)
+70 IF $PIECE(AG("EMPADDR"),U,4)'=""
Begin DoDot:3
+71 ;EMPLOYER STATE
WRITE ", ",$PIECE($GET(^DIC(5,$PIECE(AG("EMPADDR"),U,4),0)),U,2)
End DoDot:3
+72 ;EMPLOYER ZIP
WRITE ", ",$PIECE(AG("EMPADDR"),U,5),!
+73 WRITE !,?5,"[ ] NO Date of retirement : _______________",!
End DoDot:2
+74 IF $GET(AG("EMPPTR"))=""
Begin DoDot:2
+75 WRITE !,?5,"[X] YES",!
+76 WRITE !,?14,$EXTRACT(AGLINE("_"),1,50),!
+77 WRITE !,?14,$EXTRACT(AGLINE("_"),1,50),!
+78 WRITE !,?14,$EXTRACT(AGLINE("_"),1,50),!
+79 WRITE !,?5,"[ ] NO Date of retirement : _______________",!
End DoDot:2
End DoDot:1
+80 KILL AG("INSPTR"),AG("INSADDR"),AG("EMPPTR"),AG("EMPADDR"),AG("RELPTR")
+81 QUIT
