AGMSP5 ; IHS/ASDS/EFG - PRINT PAGE 5 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 V - Disability (con't)",!
I '$D(AG("MSPPRINT")) D BLANK1
I $D(AG("MSPPRINT")) D MAP1
W !,?50,"Continued on next page ==>"
W !,AGLINE("EQ")
W !,$P($G(^DIC(4,DUZ(2),0)),U),?73,"PAGE 5"
Q
BLANK1 ;THIS SECTION IS USED TO PRINT THE BLANK PAGE 5
W !,?2,"2. Is a family member currently employed ? "
W !,?5,"[ ] YES"
W !,?14,"Name and address of family member's employer : ",!
W !,?14,$E(AGLINE("_"),1,50),!
W !,?14,$E(AGLINE("_"),1,50),!
W !,?14,$E(AGLINE("_"),1,50)
W !,?5,"[ ] NO",!
W !?2,"If the patient answers 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."
W !!?2,"3. Do you have group health plan (GHP) coverage based on your own or a family"
W !,?5,"member's current employment ? "
W !,?5,"[ ] YES"
W !,?5,"[ ] NO. STOP. Medicare is primary unless the patient answered yes to"
W !?19,"questions in part I or II.",!
W !,?2,"4. Does the employer that sponsors your GHP employ 100 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 unless the patient answered yes to"
W !?19,"questions in part I or II.",!
W !!!
Q
MAP1 ;THIS SECTION IS USED TO PRINT THE PATIENT'S DATA ON THE FORM
W !,?2,"2. Is a family member currently employed ? ",!
I $P(MSPRES(9000037,AG("DA"),.44),U)=""!($P(MSPRES(9000037,AG("DA"),.44),U)="NO") D
. W !,?5,"[ ] YES",!
. W !,?14,"Name and address of family member'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"),.44),U)="" W !,?5,"[ ] NO",!
. I $P(MSPRES(9000037,AG("DA"),.44),U)="NO" W !,?5,"[X] NO",!
I $P(MSPRES(9000037,AG("DA"),.44),U)="YES" D
. S AG("EMPPTR")=$P($G(^AUPNMSP(AG("DA"),5)),U,5)
. I $G(AG("EMPPTR"))'="" D
.. S AG("EMPADDR")=$G(^AUTNEMPL(AG("EMPPTR"),0))
.. W !,?5,"[X] YES",!
.. W !,?14,"Name and address of family member's 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",!
. I $G(AG("EMPADDR"))="" D
.. W !,?5,"[X] YES",!
.. W !,?14,$E(AGLINE("_"),1,50),!
.. W !,?14,$E(AGLINE("_"),1,50),!
.. W !,?14,$E(AGLINE("_"),1,50),!
.. W !,?5,"[ ] NO",!
;
W !?2,"3. Do you have group health plan (GHP) coverage based on your own, or a family"
W !,?5,"member's current employment ? ",!
I $P(MSPRES(9000037,AG("DA"),.46),U)=""!($P(MSPRES(9000037,AG("DA"),.46),U)="NO") D
. W !,?5,"[ ] YES",!
. I $P(MSPRES(9000037,AG("DA"),.46),U)="" W !,?5,"[ ] NO",!
. I $P(MSPRES(9000037,AG("DA"),.46),U)="NO" W !,?5,"[X] NO",!
I $P(MSPRES(9000037,AG("DA"),.46),U)="YES" D
. W !,?5,"[X] YES",!
. W !,?5,"[ ] NO",!
;
W !,?2,"4. Does the employer that sponsors your GHP employ 100 or more employees ? ",!
I $P(MSPRES(9000037,AG("DA"),.47),U)=""!($P(MSPRES(9000037,AG("DA"),.47),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"),.47),U)="" W !,?5,"[ ] NO",!
. I $P(MSPRES(9000037,AG("DA"),.47),U)="NO" W !,?5,"[X] NO",!
I $P(MSPRES(9000037,AG("DA"),.47),U)="YES" D
. W !,?5,"[X] YES",!
. W !,?14,"Name and address of GHP : ",!
. I $P(MSPRES(9000037,AG("DA"),.48),U)="" D
.. W !,?14,$E(AGLINE("_"),1,50),!
.. W !,?14,$E(AGLINE("_"),1,50),!
.. W !,?14,$E(AGLINE("_"),1,50),!
. I $P(MSPRES(9000037,AG("DA"),.48),U)'="" D
.. S AG("INSPTR")=$P($G(^AUPNMSP(AG("DA"),5)),U,8)
.. S AG("INSADDR")=$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
. I $P(MSPRES(9000037,AG("DA"),.49),U)="" D
.. W !,?14,"Policy Identification Number : _______________",!
. I $P(MSPRES(9000037,AG("DA"),.49),U)'="" D
.. W !,?14,"Policy Identification Number : ",$P(MSPRES(9000037,AG("DA"),.49),U),!
. I $P(MSPRES(9000037,AG("DA"),.51),U)="" D
.. W !,?14,"Group Identification Number : _______________",!
. I $P(MSPRES(9000037,AG("DA"),.51),U)'="" D
.. W !,?14,"Group Identification Number : ",$P(MSPRES(9000037,AG("DA"),.51),U),!
. I $P(MSPRES(9000037,AG("DA"),.52),U)="" D
.. W !,?14,"Name of Policy Holder : ______________________",!
. I $P(MSPRES(9000037,AG("DA"),.52),U)'="" D
.. W !,?14,"Name of Policy Holder : ",$P(MSPRES(9000037,AG("DA"),.52),U),!
. I $P(MSPRES(9000037,AG("DA"),.53),U)="" D
.. W !,?14,"Relationship to Patient : ____________________",!
. I $P(MSPRES(9000037,AG("DA"),.53),U)'="" D
.. S AG("RELPTR")=$P($G(^AUPNMSP(AG("DA"),5)),U,12)
.. W !,?14,"Relationship to Patient : ",$P($G(^AUTTRLSH(AG("RELPTR"),0)),U),!
. W !,?5,"[ ] NO",!
K AG("INSPTR"),AG("INSADDR"),AG("EMPPTR"),AG("EMPADDR"),AG("RELPTR")
Q
AGMSP5 ; IHS/ASDS/EFG - PRINT PAGE 5 OF MSP FORM ;
+1 ;;7.1;PATIENT REGISTRATION;;AUG 25,2005
+2 ;
+3 ;I AG("MSPPRINT") EXISTS, MAP DATA FROM AUPNMSP TO THE FORM
EN ;EP
+1 WRITE !,"PART V - Disability (con't)",!
+2 IF '$DATA(AG("MSPPRINT"))
DO BLANK1
+3 IF $DATA(AG("MSPPRINT"))
DO MAP1
+4 WRITE !,?50,"Continued on next page ==>"
+5 WRITE !,AGLINE("EQ")
+6 WRITE !,$PIECE($GET(^DIC(4,DUZ(2),0)),U),?73,"PAGE 5"
+7 QUIT
BLANK1 ;THIS SECTION IS USED TO PRINT THE BLANK PAGE 5
+1 WRITE !,?2,"2. Is a family member currently employed ? "
+2 WRITE !,?5,"[ ] YES"
+3 WRITE !,?14,"Name and address of family member's employer : ",!
+4 WRITE !,?14,$EXTRACT(AGLINE("_"),1,50),!
+5 WRITE !,?14,$EXTRACT(AGLINE("_"),1,50),!
+6 WRITE !,?14,$EXTRACT(AGLINE("_"),1,50)
+7 WRITE !,?5,"[ ] NO",!
+8 WRITE !?2,"If the patient answers no to both questions 1 and 2, Medicare is primary"
+9 WRITE !?2,"unless the patient answered yes to questions in part I or II."
+10 WRITE !?2,"STOP. DO NOT PROCEED ANY FURTHER."
+11 WRITE !!?2,"3. Do you have group health plan (GHP) coverage based on your own or a family"
+12 WRITE !,?5,"member's current employment ? "
+13 WRITE !,?5,"[ ] YES"
+14 WRITE !,?5,"[ ] NO. STOP. Medicare is primary unless the patient answered yes to"
+15 WRITE !?19,"questions in part I or II.",!
+16 WRITE !,?2,"4. Does the employer that sponsors your GHP employ 100 or more employees ? ",!
+17 WRITE !,?5,"[ ] YES. STOP. The GHP is primary. Obtain the following information:",!
+18 WRITE !,?14,"Name and address of GHP : ",!
+19 WRITE !,?14,$EXTRACT(AGLINE("_"),1,50),!
+20 WRITE !,?14,$EXTRACT(AGLINE("_"),1,50),!
+21 WRITE !,?14,$EXTRACT(AGLINE("_"),1,50),!
+22 WRITE !,?14,"Policy Identification Number : _______________",!
+23 WRITE !,?14,"Group Identification Number : _______________",!
+24 WRITE !,?14,"Name of Policy Holder : ______________________",!
+25 WRITE !,?14,"Relationship to Patient : ____________________",!
+26 WRITE !,?5,"[ ] NO. STOP. Medicare is primary unless the patient answered yes to"
+27 WRITE !?19,"questions in part I or II.",!
+28 WRITE !!!
+29 QUIT
MAP1 ;THIS SECTION IS USED TO PRINT THE PATIENT'S DATA ON THE FORM
+1 WRITE !,?2,"2. Is a family member currently employed ? ",!
+2 IF $PIECE(MSPRES(9000037,AG("DA"),.44),U)=""!($PIECE(MSPRES(9000037,AG("DA"),.44),U)="NO")
Begin DoDot:1
+3 WRITE !,?5,"[ ] YES",!
+4 WRITE !,?14,"Name and address of family member's employer : ",!
+5 WRITE !,?14,$EXTRACT(AGLINE("_"),1,50),!
+6 WRITE !,?14,$EXTRACT(AGLINE("_"),1,50),!
+7 WRITE !,?14,$EXTRACT(AGLINE("_"),1,50),!
+8 IF $PIECE(MSPRES(9000037,AG("DA"),.44),U)=""
WRITE !,?5,"[ ] NO",!
+9 IF $PIECE(MSPRES(9000037,AG("DA"),.44),U)="NO"
WRITE !,?5,"[X] NO",!
End DoDot:1
+10 IF $PIECE(MSPRES(9000037,AG("DA"),.44),U)="YES"
Begin DoDot:1
+11 SET AG("EMPPTR")=$PIECE($GET(^AUPNMSP(AG("DA"),5)),U,5)
+12 IF $GET(AG("EMPPTR"))'=""
Begin DoDot:2
+13 SET AG("EMPADDR")=$GET(^AUTNEMPL(AG("EMPPTR"),0))
+14 WRITE !,?5,"[X] YES",!
+15 WRITE !,?14,"Name and address of family member's employer : ",!
+16 ;EMPLOYER NAME
WRITE !,?14,$PIECE(AG("EMPADDR"),U),!
+17 ;EMPLOYER STREET
WRITE !,?14,$PIECE(AG("EMPADDR"),U,2),!
+18 ;EMPLOYER CITY
WRITE !,?14,$PIECE(AG("EMPADDR"),U,3)
+19 IF $PIECE(AG("EMPADDR"),U,4)'=""
Begin DoDot:3
+20 ;EMPLOYER STATE
WRITE ", ",$PIECE($GET(^DIC(5,$PIECE(AG("EMPADDR"),U,4),0)),U,2)
End DoDot:3
+21 ;EMPLOYER ZIP
WRITE ", ",$PIECE(AG("EMPADDR"),U,5),!
+22 WRITE !,?5,"[ ] NO",!
End DoDot:2
+23 IF $GET(AG("EMPADDR"))=""
Begin DoDot:2
+24 WRITE !,?5,"[X] YES",!
+25 WRITE !,?14,$EXTRACT(AGLINE("_"),1,50),!
+26 WRITE !,?14,$EXTRACT(AGLINE("_"),1,50),!
+27 WRITE !,?14,$EXTRACT(AGLINE("_"),1,50),!
+28 WRITE !,?5,"[ ] NO",!
End DoDot:2
End DoDot:1
+29 ;
+30 WRITE !?2,"3. Do you have group health plan (GHP) coverage based on your own, or a family"
+31 WRITE !,?5,"member's current employment ? ",!
+32 IF $PIECE(MSPRES(9000037,AG("DA"),.46),U)=""!($PIECE(MSPRES(9000037,AG("DA"),.46),U)="NO")
Begin DoDot:1
+33 WRITE !,?5,"[ ] YES",!
+34 IF $PIECE(MSPRES(9000037,AG("DA"),.46),U)=""
WRITE !,?5,"[ ] NO",!
+35 IF $PIECE(MSPRES(9000037,AG("DA"),.46),U)="NO"
WRITE !,?5,"[X] NO",!
End DoDot:1
+36 IF $PIECE(MSPRES(9000037,AG("DA"),.46),U)="YES"
Begin DoDot:1
+37 WRITE !,?5,"[X] YES",!
+38 WRITE !,?5,"[ ] NO",!
End DoDot:1
+39 ;
+40 WRITE !,?2,"4. Does the employer that sponsors your GHP employ 100 or more employees ? ",!
+41 IF $PIECE(MSPRES(9000037,AG("DA"),.47),U)=""!($PIECE(MSPRES(9000037,AG("DA"),.47),U)="NO")
Begin DoDot:1
+42 WRITE !,?5,"[ ] YES",!
+43 WRITE !,?14,"Name and address of GHP : ",!
+44 WRITE !,?14,$EXTRACT(AGLINE("_"),1,50),!
+45 WRITE !,?14,$EXTRACT(AGLINE("_"),1,50),!
+46 WRITE !,?14,$EXTRACT(AGLINE("_"),1,50),!
+47 WRITE !,?14,"Policy Identification Number : _______________",!
+48 WRITE !,?14,"Group Identification Number : _______________",!
+49 WRITE !,?14,"Name of Policy Holder : ______________________",!
+50 WRITE !,?14,"Relationship to Patient : ____________________",!
+51 IF $PIECE(MSPRES(9000037,AG("DA"),.47),U)=""
WRITE !,?5,"[ ] NO",!
+52 IF $PIECE(MSPRES(9000037,AG("DA"),.47),U)="NO"
WRITE !,?5,"[X] NO",!
End DoDot:1
+53 IF $PIECE(MSPRES(9000037,AG("DA"),.47),U)="YES"
Begin DoDot:1
+54 WRITE !,?5,"[X] YES",!
+55 WRITE !,?14,"Name and address of GHP : ",!
+56 IF $PIECE(MSPRES(9000037,AG("DA"),.48),U)=""
Begin DoDot:2
+57 WRITE !,?14,$EXTRACT(AGLINE("_"),1,50),!
+58 WRITE !,?14,$EXTRACT(AGLINE("_"),1,50),!
+59 WRITE !,?14,$EXTRACT(AGLINE("_"),1,50),!
End DoDot:2
+60 IF $PIECE(MSPRES(9000037,AG("DA"),.48),U)'=""
Begin DoDot:2
+61 SET AG("INSPTR")=$PIECE($GET(^AUPNMSP(AG("DA"),5)),U,8)
+62 SET AG("INSADDR")=$GET(^AUTNINS(AG("INSPTR"),0))
+63 ;INSURER NAME
WRITE !,?14,$PIECE(AG("INSADDR"),U),!
+64 ;INSURER STREET
WRITE !,?14,$PIECE(AG("INSADDR"),U,2),!
+65 ;INSURER CITY
WRITE !,?14,$PIECE(AG("INSADDR"),U,3)
+66 IF $PIECE(AG("INSADDR"),U,4)'=""
Begin DoDot:3
+67 ;INSURER STATE
WRITE ", ",$PIECE($GET(^DIC(5,$PIECE(AG("INSADDR"),U,4),0)),U,2)
End DoDot:3
+68 ;INSURER ZIP
WRITE ", ",$PIECE(AG("INSADDR"),U,5),!
End DoDot:2
+69 IF $PIECE(MSPRES(9000037,AG("DA"),.49),U)=""
Begin DoDot:2
+70 WRITE !,?14,"Policy Identification Number : _______________",!
End DoDot:2
+71 IF $PIECE(MSPRES(9000037,AG("DA"),.49),U)'=""
Begin DoDot:2
+72 WRITE !,?14,"Policy Identification Number : ",$PIECE(MSPRES(9000037,AG("DA"),.49),U),!
End DoDot:2
+73 IF $PIECE(MSPRES(9000037,AG("DA"),.51),U)=""
Begin DoDot:2
+74 WRITE !,?14,"Group Identification Number : _______________",!
End DoDot:2
+75 IF $PIECE(MSPRES(9000037,AG("DA"),.51),U)'=""
Begin DoDot:2
+76 WRITE !,?14,"Group Identification Number : ",$PIECE(MSPRES(9000037,AG("DA"),.51),U),!
End DoDot:2
+77 IF $PIECE(MSPRES(9000037,AG("DA"),.52),U)=""
Begin DoDot:2
+78 WRITE !,?14,"Name of Policy Holder : ______________________",!
End DoDot:2
+79 IF $PIECE(MSPRES(9000037,AG("DA"),.52),U)'=""
Begin DoDot:2
+80 WRITE !,?14,"Name of Policy Holder : ",$PIECE(MSPRES(9000037,AG("DA"),.52),U),!
End DoDot:2
+81 IF $PIECE(MSPRES(9000037,AG("DA"),.53),U)=""
Begin DoDot:2
+82 WRITE !,?14,"Relationship to Patient : ____________________",!
End DoDot:2
+83 IF $PIECE(MSPRES(9000037,AG("DA"),.53),U)'=""
Begin DoDot:2
+84 SET AG("RELPTR")=$PIECE($GET(^AUPNMSP(AG("DA"),5)),U,12)
+85 WRITE !,?14,"Relationship to Patient : ",$PIECE($GET(^AUTTRLSH(AG("RELPTR"),0)),U),!
End DoDot:2
+86 WRITE !,?5,"[ ] NO",!
End DoDot:1
+87 KILL AG("INSPTR"),AG("INSADDR"),AG("EMPPTR"),AG("EMPADDR"),AG("RELPTR")
+88 QUIT
