AGMSP6 ; IHS/ASDS/EFG - PRINT PAGE 6 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 VI - ESRD",!
I '$D(AG("MSPPRINT")) D BLANK1
I $D(AG("MSPPRINT")) D MAP1
W !
W !,?50,"Continued on next page ==>"
W !,AGLINE("EQ")
W !,$P($G(^DIC(4,DUZ(2),0)),U),?73,"PAGE 6"
Q
BLANK1 ;THIS SECTION IS USED TO PRINT THE BLANK PAGE 6
W !,?2,"1. Do you have group health plan (GHP) coverage ? ",!
W !,?5,"[ ] YES",!
W !,?14,"Name and address of GHP : ",!
W !,?14,$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 : ____________________",!
W !,?14,"Name and address of employer, if any, from which you receive"
W !,?14,"GHP coverage : ",!
W !,?14,$E(AGLINE("_"),1,50),!
W !,?14,$E(AGLINE("_"),1,50),!
W !,?14,$E(AGLINE("_"),1,50),!
W !,?5,"[ ] NO. STOP. Medicare is primary.",!
W !,?2,"2. Have you received a kidney transplant ? ",!
W !,?5,"[ ] YES Date of transplant : _______________",!
W !,?5,"[ ] NO",!
W !,?2,"3. Have you received maintenance dialysis treatments ? ",!
W !,?5,"[ ] YES Date dialysis began : _______________",!
W !,?19,"If you participated in a self dialysis training"
W !,?19,"program, provide date training started : _______________",!
W !,?5,"[ ] NO",!
Q
MAP1 ;THIS SECTION IS USED TO PRINT THE PATIENT'S DATA ON THE FORM
W !,?2,"1. Do you have group health plan (GHP) coverage ? ",!
I $P(MSPRES(9000037,AG("DA"),.54),U)=""!($P(MSPRES(9000037,AG("DA"),.54),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,$E(AGLINE("_"),1,50),!
. W !,?14,"Policy Identification Number : _______________",!
. W !,?14,"Group Identification Number : _______________",!
. W !,?14,"Name of Policy Holder : ______________________",!
. W !,?14,"Relationship to Patient : ____________________",!
. W !,?14,"Name and address of employer, if any, from which you receive"
. W !,?14,"GHP coverage : ",!
. W !,?14,$E(AGLINE("_"),1,50),!
. W !,?14,$E(AGLINE("_"),1,50),!
. W !,?14,$E(AGLINE("_"),1,50),!
. I $P(MSPRES(9000037,AG("DA"),.54),U)="" W !,?5,"[ ] NO",!
. I $P(MSPRES(9000037,AG("DA"),.54),U)="NO" W !,?5,"[X] NO",!
I $P(MSPRES(9000037,AG("DA"),.54),U)="YES" D
. W !,?5,"[X] YES",!
. W !,?14,"Name and address of GHP : ",!
. I $P(MSPRES(9000037,AG("DA"),.55),U)="" D
.. W !,?14,$E(AGLINE("_"),1,50),!
.. W !,?14,$E(AGLINE("_"),1,50),!
.. W !,?14,$E(AGLINE("_"),1,50),!
. I $P(MSPRES(9000037,AG("DA"),.55),U)'="" D
.. S AG("INSPTR")=$P($G(^AUPNMSP(AG("DA"),6)),U,2)
.. S AG("INSADDR")=$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(^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"),.56),U)="" D
.. W !,?14,"Policy Identification Number : _______________",!
. I $P(MSPRES(9000037,AG("DA"),.56),U)'="" D
.. W !,?14,"Policy Identification Number : ",$P(MSPRES(9000037,AG("DA"),.56),U),!
. I $P(MSPRES(9000037,AG("DA"),.57),U)="" D
.. W !,?14,"Group Identification Number : _______________",!
. I $P(MSPRES(9000037,AG("DA"),.57),U)'="" D
.. W !,?14,"Group Identification Number : ",$P(MSPRES(9000037,AG("DA"),.57),U),!
. I $P(MSPRES(9000037,AG("DA"),.58),U)="" D
.. W !,?14,"Name of Policy Holder : ______________________",!
. I $P(MSPRES(9000037,AG("DA"),.58),U)'="" D
.. W !,?14,"Name of Policy Holder : ",$P(MSPRES(9000037,AG("DA"),.58),U),!
. I $P(MSPRES(9000037,AG("DA"),.59),U)="" D
.. W !,?14,"Relationship to Patient : ____________________",!
. I $P(MSPRES(9000037,AG("DA"),.59),U)'="" D
.. S AG("RELPTR")=$P($G(^AUPNMSP(AG("DA"),6)),U,6)
.. W !,?14,"Relationship to Patient : ",$P($G(^AUTTRLSH(AG("RELPTR"),0)),U),!
. W !,?14,"Name and address of employer, if any, from which you receive"
. W !,?14,"GHP coverage : ",!
. I $P(MSPRES(9000037,AG("DA"),.61),U)="" D
.. W !,?14,$E(AGLINE("_"),1,50),!
.. W !,?14,$E(AGLINE("_"),1,50),!
.. W !,?14,$E(AGLINE("_"),1,50),!
. I $P(MSPRES(9000037,AG("DA"),.61),U)'="" D
.. S AG("EMPPTR")=$P($G(^AUPNMSP(AG("DA"),6)),U,7)
.. I $G(AG("EMPPTR"))'="" D
... S AG("EMPADDR")=$G(^AUTNEMPL(AG("EMPPTR"),0))
... 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",!
;
W !,?2,"2. Have you received a kidney transplant ? ",!
I $P(MSPRES(9000037,AG("DA"),.62),U)=""!($P(MSPRES(9000037,AG("DA"),.62),U)="NO") D
. W !,?5,"[ ] YES Date of transplant : _______________",!
. I $P(MSPRES(9000037,AG("DA"),.62),U)="" W !,?5,"[ ] NO",!
. I $P(MSPRES(9000037,AG("DA"),.62),U)="NO" W !,?5,"[X] NO",!
I $P(MSPRES(9000037,AG("DA"),.62),U)="YES" D
. W !,?5,"[X] YES "
. I $P(MSPRES(9000037,AG("DA"),.63),U)="" W "Date of transplant : _______________",!
. I $P(MSPRES(9000037,AG("DA"),.63),U)'="" W "Date of transplant : ",$P(MSPRES(9000037,AG("DA"),.63),U),!
. W !,?5,"[ ] NO",!
;
W !,?2,"3. Have you received maintenance dialysis treatments ? ",!
I $P(MSPRES(9000037,AG("DA"),.64),U)=""!($P(MSPRES(9000037,AG("DA"),.64),U)="NO") D
. W !,?5,"[ ] YES Date dialysis began : _______________",!
. W !,?14,"If you participated in a self dialysis training"
. W !,?14,"program, provide date training started : _______________",!
. I $P(MSPRES(9000037,AG("DA"),.64),U)="" W !,?5,"[ ] NO",!
. I $P(MSPRES(9000037,AG("DA"),.64),U)="NO" W !,?5,"[X] NO",!
I $P(MSPRES(9000037,AG("DA"),.64),U)="YES" D
. W !,?5,"[X] YES Date dialysis began : "
. I $P(MSPRES(9000037,AG("DA"),.65),U)="" W "_______________",!
. I $P(MSPRES(9000037,AG("DA"),.65),U)'="" W $P(MSPRES(9000037,AG("DA"),.65),U),!
. W !,?14,"If you participated in a self dialysis training"
. W !,?14,"program, provide date training started : "
. I $P(MSPRES(9000037,AG("DA"),.66),U)="" W "_______________",!
. I $P(MSPRES(9000037,AG("DA"),.66),U)'="" W $P(MSPRES(9000037,AG("DA"),.66),U),!
. W !,?5,"[ ] NO",!
K AG("INSPTR"),AG("INSADDR"),AG("EMPPTR"),AG("EMPADDR"),AG("RELPTR")
Q
AGMSP6 ; IHS/ASDS/EFG - PRINT PAGE 6 OF MSP FORM ;
+1 ;;7.1;PATIENT REGISTRATION;;AUG 25,2005
+2 ;
+3 ;I AG("MSPPRINT") EXISTS, MAP DATA FROM AUPNMSP TO THE FORM
EN ;EP
+1 WRITE !,"PART VI - ESRD",!
+2 IF '$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($GET(^DIC(4,DUZ(2),0)),U),?73,"PAGE 6"
+8 QUIT
BLANK1 ;THIS SECTION IS USED TO PRINT THE BLANK PAGE 6
+1 WRITE !,?2,"1. Do you have group health plan (GHP) coverage ? ",!
+2 WRITE !,?5,"[ ] YES",!
+3 WRITE !,?14,"Name and address of GHP : ",!
+4 WRITE !,?14,$EXTRACT(AGLINE("_"),1,50),!
+5 WRITE !,?14,$EXTRACT(AGLINE("_"),1,50),!
+6 WRITE !,?14,$EXTRACT(AGLINE("_"),1,50),!
+7 WRITE !,?14,"Policy Identification Number : _______________",!
+8 WRITE !,?14,"Group Identification Number : _______________",!
+9 WRITE !,?14,"Name of Policy Holder : ______________________",!
+10 WRITE !,?14,"Relationship to Patient : ____________________",!
+11 WRITE !,?14,"Name and address of employer, if any, from which you receive"
+12 WRITE !,?14,"GHP coverage : ",!
+13 WRITE !,?14,$EXTRACT(AGLINE("_"),1,50),!
+14 WRITE !,?14,$EXTRACT(AGLINE("_"),1,50),!
+15 WRITE !,?14,$EXTRACT(AGLINE("_"),1,50),!
+16 WRITE !,?5,"[ ] NO. STOP. Medicare is primary.",!
+17 WRITE !,?2,"2. Have you received a kidney transplant ? ",!
+18 WRITE !,?5,"[ ] YES Date of transplant : _______________",!
+19 WRITE !,?5,"[ ] NO",!
+20 WRITE !,?2,"3. Have you received maintenance dialysis treatments ? ",!
+21 WRITE !,?5,"[ ] YES Date dialysis began : _______________",!
+22 WRITE !,?19,"If you participated in a self dialysis training"
+23 WRITE !,?19,"program, provide date training started : _______________",!
+24 WRITE !,?5,"[ ] NO",!
+25 QUIT
MAP1 ;THIS SECTION IS USED TO PRINT THE PATIENT'S DATA ON THE FORM
+1 WRITE !,?2,"1. Do you have group health plan (GHP) coverage ? ",!
+2 IF $PIECE(MSPRES(9000037,AG("DA"),.54),U)=""!($PIECE(MSPRES(9000037,AG("DA"),.54),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,$EXTRACT(AGLINE("_"),1,50),!
+8 WRITE !,?14,"Policy Identification Number : _______________",!
+9 WRITE !,?14,"Group Identification Number : _______________",!
+10 WRITE !,?14,"Name of Policy Holder : ______________________",!
+11 WRITE !,?14,"Relationship to Patient : ____________________",!
+12 WRITE !,?14,"Name and address of employer, if any, from which you receive"
+13 WRITE !,?14,"GHP coverage : ",!
+14 WRITE !,?14,$EXTRACT(AGLINE("_"),1,50),!
+15 WRITE !,?14,$EXTRACT(AGLINE("_"),1,50),!
+16 WRITE !,?14,$EXTRACT(AGLINE("_"),1,50),!
+17 IF $PIECE(MSPRES(9000037,AG("DA"),.54),U)=""
WRITE !,?5,"[ ] NO",!
+18 IF $PIECE(MSPRES(9000037,AG("DA"),.54),U)="NO"
WRITE !,?5,"[X] NO",!
End DoDot:1
+19 IF $PIECE(MSPRES(9000037,AG("DA"),.54),U)="YES"
Begin DoDot:1
+20 WRITE !,?5,"[X] YES",!
+21 WRITE !,?14,"Name and address of GHP : ",!
+22 IF $PIECE(MSPRES(9000037,AG("DA"),.55),U)=""
Begin DoDot:2
+23 WRITE !,?14,$EXTRACT(AGLINE("_"),1,50),!
+24 WRITE !,?14,$EXTRACT(AGLINE("_"),1,50),!
+25 WRITE !,?14,$EXTRACT(AGLINE("_"),1,50),!
End DoDot:2
+26 IF $PIECE(MSPRES(9000037,AG("DA"),.55),U)'=""
Begin DoDot:2
+27 SET AG("INSPTR")=$PIECE($GET(^AUPNMSP(AG("DA"),6)),U,2)
+28 SET AG("INSADDR")=$GET(^AUTNINS(AG("INSPTR"),0))
+29 ;INSURER NAME
WRITE !,?14,$PIECE(AG("INSADDR"),U),!
+30 ;INSURER STREET
WRITE !,?14,$PIECE(AG("INSADDR"),U,2),!
+31 ;INSURER CITY
WRITE !,?14,$PIECE(AG("INSADDR"),U,3)
+32 IF $PIECE(AG("INSADDR"),U,4)'=""
Begin DoDot:3
+33 ;INSURER STATE
WRITE ", ",$PIECE(^DIC(5,$PIECE(AG("INSADDR"),U,4),0),U,2)
End DoDot:3
+34 ;INSURER ZIP
WRITE ", ",$PIECE(AG("INSADDR"),U,5),!
End DoDot:2
+35 IF $PIECE(MSPRES(9000037,AG("DA"),.56),U)=""
Begin DoDot:2
+36 WRITE !,?14,"Policy Identification Number : _______________",!
End DoDot:2
+37 IF $PIECE(MSPRES(9000037,AG("DA"),.56),U)'=""
Begin DoDot:2
+38 WRITE !,?14,"Policy Identification Number : ",$PIECE(MSPRES(9000037,AG("DA"),.56),U),!
End DoDot:2
+39 IF $PIECE(MSPRES(9000037,AG("DA"),.57),U)=""
Begin DoDot:2
+40 WRITE !,?14,"Group Identification Number : _______________",!
End DoDot:2
+41 IF $PIECE(MSPRES(9000037,AG("DA"),.57),U)'=""
Begin DoDot:2
+42 WRITE !,?14,"Group Identification Number : ",$PIECE(MSPRES(9000037,AG("DA"),.57),U),!
End DoDot:2
+43 IF $PIECE(MSPRES(9000037,AG("DA"),.58),U)=""
Begin DoDot:2
+44 WRITE !,?14,"Name of Policy Holder : ______________________",!
End DoDot:2
+45 IF $PIECE(MSPRES(9000037,AG("DA"),.58),U)'=""
Begin DoDot:2
+46 WRITE !,?14,"Name of Policy Holder : ",$PIECE(MSPRES(9000037,AG("DA"),.58),U),!
End DoDot:2
+47 IF $PIECE(MSPRES(9000037,AG("DA"),.59),U)=""
Begin DoDot:2
+48 WRITE !,?14,"Relationship to Patient : ____________________",!
End DoDot:2
+49 IF $PIECE(MSPRES(9000037,AG("DA"),.59),U)'=""
Begin DoDot:2
+50 SET AG("RELPTR")=$PIECE($GET(^AUPNMSP(AG("DA"),6)),U,6)
+51 WRITE !,?14,"Relationship to Patient : ",$PIECE($GET(^AUTTRLSH(AG("RELPTR"),0)),U),!
End DoDot:2
+52 WRITE !,?14,"Name and address of employer, if any, from which you receive"
+53 WRITE !,?14,"GHP coverage : ",!
+54 IF $PIECE(MSPRES(9000037,AG("DA"),.61),U)=""
Begin DoDot:2
+55 WRITE !,?14,$EXTRACT(AGLINE("_"),1,50),!
+56 WRITE !,?14,$EXTRACT(AGLINE("_"),1,50),!
+57 WRITE !,?14,$EXTRACT(AGLINE("_"),1,50),!
End DoDot:2
+58 IF $PIECE(MSPRES(9000037,AG("DA"),.61),U)'=""
Begin DoDot:2
+59 SET AG("EMPPTR")=$PIECE($GET(^AUPNMSP(AG("DA"),6)),U,7)
+60 IF $GET(AG("EMPPTR"))'=""
Begin DoDot:3
+61 SET AG("EMPADDR")=$GET(^AUTNEMPL(AG("EMPPTR"),0))
+62 ;EMPLOYER NAME
WRITE !,?14,$PIECE(AG("EMPADDR"),U),!
+63 ;EMPLOYER STREET
WRITE !,?14,$PIECE(AG("EMPADDR"),U,2),!
+64 ;EMPLOYER CITY
WRITE !,?14,$PIECE(AG("EMPADDR"),U,3)
+65 IF $PIECE(AG("EMPADDR"),U,4)'=""
Begin DoDot:4
+66 ;EMPLOYER STATE
WRITE ", ",$PIECE($GET(^DIC(5,$PIECE(AG("EMPADDR"),U,4),0)),U,2)
End DoDot:4
+67 ;EMPLOYER ZIP
WRITE ", ",$PIECE(AG("EMPADDR"),U,5),!
End DoDot:3
End DoDot:2
+68 WRITE !,?5,"[ ] NO",!
End DoDot:1
+69 ;
+70 WRITE !,?2,"2. Have you received a kidney transplant ? ",!
+71 IF $PIECE(MSPRES(9000037,AG("DA"),.62),U)=""!($PIECE(MSPRES(9000037,AG("DA"),.62),U)="NO")
Begin DoDot:1
+72 WRITE !,?5,"[ ] YES Date of transplant : _______________",!
+73 IF $PIECE(MSPRES(9000037,AG("DA"),.62),U)=""
WRITE !,?5,"[ ] NO",!
+74 IF $PIECE(MSPRES(9000037,AG("DA"),.62),U)="NO"
WRITE !,?5,"[X] NO",!
End DoDot:1
+75 IF $PIECE(MSPRES(9000037,AG("DA"),.62),U)="YES"
Begin DoDot:1
+76 WRITE !,?5,"[X] YES "
+77 IF $PIECE(MSPRES(9000037,AG("DA"),.63),U)=""
WRITE "Date of transplant : _______________",!
+78 IF $PIECE(MSPRES(9000037,AG("DA"),.63),U)'=""
WRITE "Date of transplant : ",$PIECE(MSPRES(9000037,AG("DA"),.63),U),!
+79 WRITE !,?5,"[ ] NO",!
End DoDot:1
+80 ;
+81 WRITE !,?2,"3. Have you received maintenance dialysis treatments ? ",!
+82 IF $PIECE(MSPRES(9000037,AG("DA"),.64),U)=""!($PIECE(MSPRES(9000037,AG("DA"),.64),U)="NO")
Begin DoDot:1
+83 WRITE !,?5,"[ ] YES Date dialysis began : _______________",!
+84 WRITE !,?14,"If you participated in a self dialysis training"
+85 WRITE !,?14,"program, provide date training started : _______________",!
+86 IF $PIECE(MSPRES(9000037,AG("DA"),.64),U)=""
WRITE !,?5,"[ ] NO",!
+87 IF $PIECE(MSPRES(9000037,AG("DA"),.64),U)="NO"
WRITE !,?5,"[X] NO",!
End DoDot:1
+88 IF $PIECE(MSPRES(9000037,AG("DA"),.64),U)="YES"
Begin DoDot:1
+89 WRITE !,?5,"[X] YES Date dialysis began : "
+90 IF $PIECE(MSPRES(9000037,AG("DA"),.65),U)=""
WRITE "_______________",!
+91 IF $PIECE(MSPRES(9000037,AG("DA"),.65),U)'=""
WRITE $PIECE(MSPRES(9000037,AG("DA"),.65),U),!
+92 WRITE !,?14,"If you participated in a self dialysis training"
+93 WRITE !,?14,"program, provide date training started : "
+94 IF $PIECE(MSPRES(9000037,AG("DA"),.66),U)=""
WRITE "_______________",!
+95 IF $PIECE(MSPRES(9000037,AG("DA"),.66),U)'=""
WRITE $PIECE(MSPRES(9000037,AG("DA"),.66),U),!
+96 WRITE !,?5,"[ ] NO",!
End DoDot:1
+97 KILL AG("INSPTR"),AG("INSADDR"),AG("EMPPTR"),AG("EMPADDR"),AG("RELPTR")
+98 QUIT
