AGMSP7 ; IHS/ASDS/EFG - PRINT PAGE 7 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 (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 7"
Q
BLANK1 ;THIS SECTION IS USED TO PRINT THE BLANK PAGE 7
W !,?2,"4. Are you within the 30 month coordination period ? ",!
W !,?5,"[ ] YES",!
W !,?5,"[ ] NO. STOP. Medicare is primary.",!
W !,?2,"5. Are you entitled to Medicare on the basis of either ESRD and age or ESRD"
W !,?5,"and disability ? ",!
W !,?5,"[ ] YES",!
W !,?5,"[ ] NO. STOP. The group health plan (GHP) is primary during the 30-month"
W !?19,"coordination period.",!
W !,?2,"6. Was your initial entitlement to Medicare (including simultaneous"
W !,?5,"entitlement) based on ESRD ? ",!
W !,?5,"[ ] YES. STOP. The GHP continues to pay primary during the 30-month"
W !?19,"coordination period.",!
W !,?5,"[ ] NO. Initial entitlement is based on age or diability.",!
W !,?2,"7. Does the working aged or disability MSP provision apply (i.e., is the GHP"
W !,?5,"primary based on age or disability entitlement) ? ",!
W !,?5,"[ ] YES. The GHP continues to pay primary during the 30-month"
W !?14,"coordination period.",!
W !,?5,"[ ] NO. Medicare continues to pay primary.",!
W !!!
W !,?2," SIGNATURE : ______________________________"
W !,?2," SIGNATURE DATE : __________________"
W !,?2,"DATE SURVEY GIVEN : __________________"
Q
MAP1 ;THIS SECTION IS USED TO PRINT THE PATIENT'S DATA ON THE FORM
W !,?2,"4. Are you within the 30 month coordination period ? ",!
I $P(MSPRES(9000037,AG("DA"),.67),U)=""!($P(MSPRES(9000037,AG("DA"),.67),U)="NO") D
. W !,?5,"[ ] YES",!
. I $P(MSPRES(9000037,AG("DA"),.67),U)="" W !,?5,"[ ] NO",!
. I $P(MSPRES(9000037,AG("DA"),.67),U)="NO" W !,?5,"[X] NO",!
I $P(MSPRES(9000037,AG("DA"),.67),U)="YES" D
. W !,?5,"[X] YES",!
. W !,?5,"[ ] NO",!
;
W !,?2,"5. Are you entitled to Medicare on the basis of either ESRD and age or ESRD"
W !,?5,"and disability ? ",!
I $P(MSPRES(9000037,AG("DA"),.68),U)=""!($P(MSPRES(9000037,AG("DA"),.68),U)="NO") D
. W !,?5,"[ ] YES",!
. I $P(MSPRES(9000037,AG("DA"),.68),U)="" W !,?5,"[ ] NO",!
. I $P(MSPRES(9000037,AG("DA"),.68),U)="NO" W !,?5,"[X] NO",!
I $P(MSPRES(9000037,AG("DA"),.68),U)="YES" D
. W !,?5,"[X] YES",!
. W !,?5,"[ ] NO",!
;
W !,?2,"6. Was your initial entitlement to Medicare (including simultaneous"
W !,?5,"entitlement) based on ESRD ? ",!
I $P(MSPRES(9000037,AG("DA"),.69),U)=""!($P(MSPRES(9000037,AG("DA"),.69),U)="NO") D
. W !,?5,"[ ] YES",!
. I $P(MSPRES(9000037,AG("DA"),.69),U)="" W !,?5,"[ ] NO",!
. I $P(MSPRES(9000037,AG("DA"),.69),U)="NO" W !,?5,"[X] NO",!
I $P(MSPRES(9000037,AG("DA"),.69),U)="YES" D
. W !,?5,"[X] YES",!
. W !,?5,"[ ] NO",!
;
W !,?2,"7. Does the working aged or disability MSP provision apply (i.e., is the GHP"
W !,?5,"primary based on age or disability entitlement) ? ",!
I $P(MSPRES(9000037,AG("DA"),.71),U)=""!($P(MSPRES(9000037,AG("DA"),.71),U)="NO") D
. W !,?5,"[ ] YES",!
. I $P(MSPRES(9000037,AG("DA"),.71),U)="" W !,?5,"[ ] NO",!
. I $P(MSPRES(9000037,AG("DA"),.71),U)="NO" W !,?5,"[X] NO",!
I $P(MSPRES(9000037,AG("DA"),.71),U)="YES" D
. W !,?5,"[X] YES",!
. W !,?5,"[ ] NO",!
;
W !!!
S $P(SIGLINE,"_",30)=""
W !,?2,"SIGNATURE : ",SIGLINE ;,$P(MSPRES(9000037,AG("DA"),.02),U)
S Y=$P($G(^AUPNMSP(AG("DA"),7)),U)
X ^DD("DD")
W !?2,"SIGNATURE DATE : ",Y
W !!?2,"DATE SURVEY GIVEN: ",$P(MSPRES(9000037,AG("DA"),.01),U)
Q
AGMSP7 ; IHS/ASDS/EFG - PRINT PAGE 7 OF MSP FORM ;
+1 ;;7.1;PATIENT REGISTRATION;;AUG 25,2005
+2 ;
+3 ;I AG("MSPPRINT") EXISTS, MAP DATA FROM AUPNMSP TO THE FORM
EN ;EP
+1 WRITE !,"PART VI - ESRD (con't)",!
+2 IF '$DATA(AG("MSPPRINT"))
DO BLANK1
+3 IF $DATA(AG("MSPPRINT"))
DO MAP1
+4 WRITE !!!!!!!!!
+5 ;W !,?50,"Continued on next page ==>"
+6 WRITE !,AGLINE("EQ")
+7 WRITE !,$PIECE($GET(^DIC(4,DUZ(2),0)),U),?73,"PAGE 7"
+8 QUIT
BLANK1 ;THIS SECTION IS USED TO PRINT THE BLANK PAGE 7
+1 WRITE !,?2,"4. Are you within the 30 month coordination period ? ",!
+2 WRITE !,?5,"[ ] YES",!
+3 WRITE !,?5,"[ ] NO. STOP. Medicare is primary.",!
+4 WRITE !,?2,"5. Are you entitled to Medicare on the basis of either ESRD and age or ESRD"
+5 WRITE !,?5,"and disability ? ",!
+6 WRITE !,?5,"[ ] YES",!
+7 WRITE !,?5,"[ ] NO. STOP. The group health plan (GHP) is primary during the 30-month"
+8 WRITE !?19,"coordination period.",!
+9 WRITE !,?2,"6. Was your initial entitlement to Medicare (including simultaneous"
+10 WRITE !,?5,"entitlement) based on ESRD ? ",!
+11 WRITE !,?5,"[ ] YES. STOP. The GHP continues to pay primary during the 30-month"
+12 WRITE !?19,"coordination period.",!
+13 WRITE !,?5,"[ ] NO. Initial entitlement is based on age or diability.",!
+14 WRITE !,?2,"7. Does the working aged or disability MSP provision apply (i.e., is the GHP"
+15 WRITE !,?5,"primary based on age or disability entitlement) ? ",!
+16 WRITE !,?5,"[ ] YES. The GHP continues to pay primary during the 30-month"
+17 WRITE !?14,"coordination period.",!
+18 WRITE !,?5,"[ ] NO. Medicare continues to pay primary.",!
+19 WRITE !!!
+20 WRITE !,?2," SIGNATURE : ______________________________"
+21 WRITE !,?2," SIGNATURE DATE : __________________"
+22 WRITE !,?2,"DATE SURVEY GIVEN : __________________"
+23 QUIT
MAP1 ;THIS SECTION IS USED TO PRINT THE PATIENT'S DATA ON THE FORM
+1 WRITE !,?2,"4. Are you within the 30 month coordination period ? ",!
+2 IF $PIECE(MSPRES(9000037,AG("DA"),.67),U)=""!($PIECE(MSPRES(9000037,AG("DA"),.67),U)="NO")
Begin DoDot:1
+3 WRITE !,?5,"[ ] YES",!
+4 IF $PIECE(MSPRES(9000037,AG("DA"),.67),U)=""
WRITE !,?5,"[ ] NO",!
+5 IF $PIECE(MSPRES(9000037,AG("DA"),.67),U)="NO"
WRITE !,?5,"[X] NO",!
End DoDot:1
+6 IF $PIECE(MSPRES(9000037,AG("DA"),.67),U)="YES"
Begin DoDot:1
+7 WRITE !,?5,"[X] YES",!
+8 WRITE !,?5,"[ ] NO",!
End DoDot:1
+9 ;
+10 WRITE !,?2,"5. Are you entitled to Medicare on the basis of either ESRD and age or ESRD"
+11 WRITE !,?5,"and disability ? ",!
+12 IF $PIECE(MSPRES(9000037,AG("DA"),.68),U)=""!($PIECE(MSPRES(9000037,AG("DA"),.68),U)="NO")
Begin DoDot:1
+13 WRITE !,?5,"[ ] YES",!
+14 IF $PIECE(MSPRES(9000037,AG("DA"),.68),U)=""
WRITE !,?5,"[ ] NO",!
+15 IF $PIECE(MSPRES(9000037,AG("DA"),.68),U)="NO"
WRITE !,?5,"[X] NO",!
End DoDot:1
+16 IF $PIECE(MSPRES(9000037,AG("DA"),.68),U)="YES"
Begin DoDot:1
+17 WRITE !,?5,"[X] YES",!
+18 WRITE !,?5,"[ ] NO",!
End DoDot:1
+19 ;
+20 WRITE !,?2,"6. Was your initial entitlement to Medicare (including simultaneous"
+21 WRITE !,?5,"entitlement) based on ESRD ? ",!
+22 IF $PIECE(MSPRES(9000037,AG("DA"),.69),U)=""!($PIECE(MSPRES(9000037,AG("DA"),.69),U)="NO")
Begin DoDot:1
+23 WRITE !,?5,"[ ] YES",!
+24 IF $PIECE(MSPRES(9000037,AG("DA"),.69),U)=""
WRITE !,?5,"[ ] NO",!
+25 IF $PIECE(MSPRES(9000037,AG("DA"),.69),U)="NO"
WRITE !,?5,"[X] NO",!
End DoDot:1
+26 IF $PIECE(MSPRES(9000037,AG("DA"),.69),U)="YES"
Begin DoDot:1
+27 WRITE !,?5,"[X] YES",!
+28 WRITE !,?5,"[ ] NO",!
End DoDot:1
+29 ;
+30 WRITE !,?2,"7. Does the working aged or disability MSP provision apply (i.e., is the GHP"
+31 WRITE !,?5,"primary based on age or disability entitlement) ? ",!
+32 IF $PIECE(MSPRES(9000037,AG("DA"),.71),U)=""!($PIECE(MSPRES(9000037,AG("DA"),.71),U)="NO")
Begin DoDot:1
+33 WRITE !,?5,"[ ] YES",!
+34 IF $PIECE(MSPRES(9000037,AG("DA"),.71),U)=""
WRITE !,?5,"[ ] NO",!
+35 IF $PIECE(MSPRES(9000037,AG("DA"),.71),U)="NO"
WRITE !,?5,"[X] NO",!
End DoDot:1
+36 IF $PIECE(MSPRES(9000037,AG("DA"),.71),U)="YES"
Begin DoDot:1
+37 WRITE !,?5,"[X] YES",!
+38 WRITE !,?5,"[ ] NO",!
End DoDot:1
+39 ;
+40 WRITE !!!
+41 SET $PIECE(SIGLINE,"_",30)=""
+42 ;,$P(MSPRES(9000037,AG("DA"),.02),U)
WRITE !,?2,"SIGNATURE : ",SIGLINE
+43 SET Y=$PIECE($GET(^AUPNMSP(AG("DA"),7)),U)
+44 XECUTE ^DD("DD")
+45 WRITE !?2,"SIGNATURE DATE : ",Y
+46 WRITE !!?2,"DATE SURVEY GIVEN: ",$PIECE(MSPRES(9000037,AG("DA"),.01),U)
+47 QUIT
