- 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