DG1010P1 ;ALB/REW - VA FORM 10-10 (CONT) ; 26 MAY 92
;;5.3;Registration;**489**;Aug 13, 1993
; DGP(N) = NTH NODE OF PATIENT FILE - ALREADY DEFINED
ST W !?25,"SEE ATTACHMENT FOR PAPERWORK REDUCTION INFORMATION AND PRIVACY ACT INFORMATION",!,DGLDASH
I $G(IOST)["C-" S DGLUND=""
PARTI W !?54,"PART I - PATIENT DATA",!,DGLUND
S DGD=+$P(DGP("DIS",0),U,3) W !,"1. Type of benefit applied for: ",$P("HOSPITAL/OUTPATIENT TREATMENT^DOMICILIARY CARE^HOSPITAL/OUTPATIENT TREATMENT^OUTPATIENT DENTAL^NURSING HOME CARE",U,+DGD)
W !,DGLUND
W !,"2. Applicant's Name ",?48,"|"," 3. Other names used (Alias)",?86,"|"," 4. Social Security Number"
S DGX=$O(^DPT(DFN,.01,0)) S DGA=$P($G(^DPT(DFN,.01,+DGX,0)),U,1)
W !?5,DGNAM,?48,"|",?54,DGA,?86,"|",?92,DGSS
F S DGX=$O(^DPT(DFN,.01,DGX)) Q:DGX'>0 W !?48,"|",?54,$P($G(^DPT(DFN,.01,DGX,0)),U,1),?86,"|"
W ?131,"",$C(13),DGLUND
CLAIM ;
W !,"5. Claim Number",?23,"| 6. LOCATION OF CLAIMS FOLDER",?60,"| 7. DATE OF BIRTH",?86,"| 8. PLACE OF BIRTH"
S DGX=$$DISP^DG1010P0(DGP(.31),3)
W !?5,$S('DGUNK:"C- ",1:""),DGX,?23,"| ",$E($$DISP^DG1010P0(DGP(.31),2),1,30),?60,"| ",$$DATENP^DG1010P0(DGP(0),3)
S DGD=$$DISP^DG1010P0(DGP(0),11,0,1),DGNOCITY=DGUNK,DGD1=$$POINT^DG1010P0(DGP(0),12,5,1,0,1)
W ?86,"| ",$E($S((DGNOCITY&DGUNK):"UNANSWERED",1:DGD_$S(($L(DGD)):", ",1:"")_DGD1),1,39),?131,$C(13),DGLUND
HEADADD ;
S DGD1=$$DATENP^DG1010P0(DGP(.121),7,0,1) ;FROM
S DGD2=$$DATENP^DG1010P0(DGP(.121),8,0,1) ;TO
W !,"9. PERMANENT ADDRESS",?66,"|"," 10. TEMPORARY ADDRESS "
S DGDMAX=1
PRTTMP ; DGTMP=0 IF TEMP ADDRES ENTER NOT=Y OR END DATE IN PAST
K DGD
S DGTMP=1
I ($P(DGP(.121),U,9)'="Y")!(($P(DGP(.121),U,8)>0)&($P(DGP(.121),U,8)<(9999999-DFN1))) S DGTMP=0 S DGD(.121,1)="NOT APPLICABLE" F DGDPC=2:1:5,12 S DGD(.121,DGDPC)=""
W:(DGTMP=1)&($L(DGD1)!($L(DGD2))) "(FROM ",DGD1," TO ",DGD2,?126,")"
W !,DGL2
GETADD ;
STR2ZIP F DGI=.11,.121 Q:((DGI=.121)&(DGTMP=0)) D
.;ADDR=1-3,4-5=CITY,STATE,12=ZIP+4
.F DGDPC=1:1:5,12 D
..I ("^1^4^12^"[DGDPC) S DGD(DGI,DGDPC)=$$DISP^DG1010P0(DGP(DGI),DGDPC) I DGDPC=12,(DGD(DGI,12)?9N) S DGD(DGI,12)=$E(DGD(DGI,12),1,5)_"-"_$E(DGD(DGI,12),6,9)
..I ("23"[DGDPC) S DGD(DGI,DGDPC)=$$DISP^DG1010P0(DGP(DGI),DGDPC,0,1) S:(DGDMAX<DGDPC)&($L(DGD(DGI,DGDPC))) DGDMAX=DGDPC
..I (DGDPC=5) S X=$$POINT^DG1010P0(DGP(DGI),5,5,1),DGD(DGI,5)=$S(($L(X)<19):X,$L($$POINT^DG1010P0(DGP(DGI),5,5,2,0,1)):$$POINT^DG1010P0(DGP(DGI),5,5,2),1:$E(X,1,18))
S:(DGTMP=0) DGD(.121,11)=""
WRADD W !,"9A. STREET ADDRESS:",?21,DGD(.11,1),?66,"|"," 10A. STREET ADDRESS:",?89,DGD(.121,1)
W:(DGDMAX>1) !?21,DGD(.11,2),?66,"|",?89,DGD(.121,2)
W:(DGDMAX>2) !?21,DGD(.11,3),?66,"|",?89,DGD(.121,3)
W !,DGL2
W !,"9B. CITY: ",DGD(.11,4),?33,"| ","9C. STATE: ",DGD(.11,5),?66,"|"," 10B. CITY: ",$E(DGD(.121,4),1,20),?99,"| ","10C. STATE: ",DGD(.121,5),!,DGL2
W !,"9D. ZIP CODE: ",DGD(.11,12),?33,"| ","9E. COUNTY: ",$$POINT^DG1010P0(DGP(.11),7,("^DIC(5,"_+$P(DGP(.11),U,5)_",1,"),0),?66,"| "
W "10D. ZIP CODE: ",DGD(.121,12),?99,"| ","10E. COUNTY: "
W:(DGTMP=1) $$POINT^DG1010P0(DGP(.121),11,("^DIC(5,"_+$P(DGP(.121),U,5)_",1,"),0)
W !,DGL2
W !,"9F. HOME TELEPHONE NUMBER: ",$$DISP^DG1010P0(DGP(.13),1),?66,"| ","10F. HOME TELEPHONE NUMBER:",?96
W:DGTMP $$DISP^DG1010P0(DGP(.121),10)
W !,DGLUND
CA ;Display confidential address information
N DGACT,DGCAT,DGCATN,DGCATS,VAPA
D ADD^VADPT
W !,"11. CONFIDENTIAL ADDRESS",?66,"|"
I VAPA(12)=""!(VAPA(12)=0) D G SEX
.W !?11,"Not Applicable",?66,"|"
.W !,DGLUND
W !,DGL2
W !,"11A. STREET ADDRESS:",?21,VAPA(13)
W ?66,"| ","11B. CITY: ",$E(VAPA(16),0,19),?99,"| 11C. STATE: ",$P(VAPA(17),"^",2)
W !,?21,VAPA(14)
W ?66,"| ","11D. ZIP CODE: ",$P(VAPA(18),"^",2),?99,"| 11E. COUNTY: ",$P(VAPA(19),"^",2)
W !,?21,VAPA(15),?66,"| 11F. START DATE: ",$P(VAPA(20),"^",2),?99,"| STOP DATE: ",$P(VAPA(21),"^",2)
W !,$E(DGL2,1,99),"|",$E(DGL2,1,32)
W !,"11G. Active Confidential Address Categories",?66,"|"
S DGCATS="" F S DGCATS=$O(VAPA(22,DGCATS)) Q:DGCATS="" D
.S DGCAT=VAPA(22,DGCATS),DGACT=$P(DGCAT,"^",3),DGCATN=$P(DGCAT,"^",2)
.I DGACT="Y" W !?11,DGCATN,?66,"|"
W !,DGLUND
SEX K DGD,DGX
W !,"12. PATIENT'S SEX",?33,"| ","13. MOTHER'S MAIDEN NAME",?66,"| ","14. MOTHER'S NAME",?99,"| ","15. FATHER'S NAME"
S X=$P(DGP(0),U,2) W !?5,$S((X="M"):"MALE",(X="F"):"FEMALE",1:"UNANSWERED")
W ?33,"| ",?40,$E(($$DISP^DG1010P0(DGP(.24),3)),1,25),?66,"| ",?73,$E(($$DISP^DG1010P0(DGP(.24),2)),1,23),?99,"| ",?106,$E(($$DISP^DG1010P0(DGP(.24),1)),1,30),?131,$C(13),DGLUND
RELIG ;
W !,"16. RELIGIOUS PREFERENCE",?33,"| ","17. DATE OF PREVIOUS CARE",?66,"| ","18. LOCATION OF PREVIOUS CARE",?99,"| ","19. SPINAL CORD INJURY"
W !?5,$$POINT^DG1010P0(DGP(0),8,13),?33,"| ",?40,$$DATENP^DG1010P0(DGP(1010.15),1),?66,"| ",?73,$$POINT^DG1010P0(DGP(1010.15),2,4)
S X=$$UNK^DG1010P0($P(DGP(57),U,4))
W ?99,"| ",?106,$S((DGUNK):X,(X=1):"PARAPLEGIA-TRAUMATIC",(X=2):"QUADRIPLEGIA-TRAUMATIC",(X=3):"PARAPLEGIA-NONTRAUMATIC",(X=4):"QUADRIPLEGIA-NONTRAUMATIC",(X="X"):"NOT APPLICABLE",1:"INVALID"),?131,$C(13),DGLUND,!
CONTD ;
G CONT^DG1010P2
;
DG1010P1 ;ALB/REW - VA FORM 10-10 (CONT) ; 26 MAY 92
+1 ;;5.3;Registration;**489**;Aug 13, 1993
+2 ; DGP(N) = NTH NODE OF PATIENT FILE - ALREADY DEFINED
ST WRITE !?25,"SEE ATTACHMENT FOR PAPERWORK REDUCTION INFORMATION AND PRIVACY ACT INFORMATION",!,DGLDASH
+1 IF $GET(IOST)["C-"
SET DGLUND=""
PARTI WRITE !?54,"PART I - PATIENT DATA",!,DGLUND
+1 SET DGD=+$PIECE(DGP("DIS",0),U,3)
WRITE !,"1. Type of benefit applied for: ",$PIECE("HOSPITAL/OUTPATIENT TREATMENT^DOMICILIARY CARE^HOSPITAL/OUTPATIENT TREATMENT^OUTPATIENT DENTAL^NURSING HOME CARE",U,+DGD)
+2 WRITE !,DGLUND
+3 WRITE !,"2. Applicant's Name ",?48,"|"," 3. Other names used (Alias)",?86,"|"," 4. Social Security Number"
+4 SET DGX=$ORDER(^DPT(DFN,.01,0))
SET DGA=$PIECE($GET(^DPT(DFN,.01,+DGX,0)),U,1)
+5 WRITE !?5,DGNAM,?48,"|",?54,DGA,?86,"|",?92,DGSS
+6 FOR
SET DGX=$ORDER(^DPT(DFN,.01,DGX))
IF DGX'>0
QUIT
WRITE !?48,"|",?54,$PIECE($GET(^DPT(DFN,.01,DGX,0)),U,1),?86,"|"
+7 WRITE ?131,"",$CHAR(13),DGLUND
CLAIM ;
+1 WRITE !,"5. Claim Number",?23,"| 6. LOCATION OF CLAIMS FOLDER",?60,"| 7. DATE OF BIRTH",?86,"| 8. PLACE OF BIRTH"
+2 SET DGX=$$DISP^DG1010P0(DGP(.31),3)
+3 WRITE !?5,$SELECT('DGUNK:"C- ",1:""),DGX,?23,"| ",$EXTRACT($$DISP^DG1010P0(DGP(.31),2),1,30),?60,"| ",$$DATENP^DG1010P0(DGP(0),3)
+4 SET DGD=$$DISP^DG1010P0(DGP(0),11,0,1)
SET DGNOCITY=DGUNK
SET DGD1=$$POINT^DG1010P0(DGP(0),12,5,1,0,1)
+5 WRITE ?86,"| ",$EXTRACT($SELECT((DGNOCITY&DGUNK):"UNANSWERED",1:DGD_$SELECT(($LENGTH(DGD)):", ",1:"")_DGD1),1,39),?131,$CHAR(13),DGLUND
HEADADD ;
+1 ;FROM
SET DGD1=$$DATENP^DG1010P0(DGP(.121),7,0,1)
+2 ;TO
SET DGD2=$$DATENP^DG1010P0(DGP(.121),8,0,1)
+3 WRITE !,"9. PERMANENT ADDRESS",?66,"|"," 10. TEMPORARY ADDRESS "
+4 SET DGDMAX=1
PRTTMP ; DGTMP=0 IF TEMP ADDRES ENTER NOT=Y OR END DATE IN PAST
+1 KILL DGD
+2 SET DGTMP=1
+3 IF ($PIECE(DGP(.121),U,9)'="Y")!(($PIECE(DGP(.121),U,8)>0)&($PIECE(DGP(.121),U,8)<(9999999-DFN1)))
SET DGTMP=0
SET DGD(.121,1)="NOT APPLICABLE"
FOR DGDPC=2:1:5,12
SET DGD(.121,DGDPC)=""
+4 IF (DGTMP=1)&($LENGTH(DGD1)!($LENGTH(DGD2)))
WRITE "(FROM ",DGD1," TO ",DGD2,?126,")"
+5 WRITE !,DGL2
GETADD ;
STR2ZIP FOR DGI=.11,.121
IF ((DGI=.121)&(DGTMP=0))
QUIT
Begin DoDot:1
+1 ;ADDR=1-3,4-5=CITY,STATE,12=ZIP+4
+2 FOR DGDPC=1:1:5,12
Begin DoDot:2
+3 IF ("^1^4^12^"[DGDPC)
SET DGD(DGI,DGDPC)=$$DISP^DG1010P0(DGP(DGI),DGDPC)
IF DGDPC=12
IF (DGD(DGI,12)?9N)
SET DGD(DGI,12)=$EXTRACT(DGD(DGI,12),1,5)_"-"_$EXTRACT(DGD(DGI,12),6,9)
+4 IF ("23"[DGDPC)
SET DGD(DGI,DGDPC)=$$DISP^DG1010P0(DGP(DGI),DGDPC,0,1)
IF (DGDMAX<DGDPC)&($LENGTH(DGD(DGI,DGDPC)))
SET DGDMAX=DGDPC
+5 IF (DGDPC=5)
SET X=$$POINT^DG1010P0(DGP(DGI),5,5,1)
SET DGD(DGI,5)=$SELECT(($LENGTH(X)<19):X,$LENGTH($$POINT^DG1010P0(DGP(DGI),5,5,2,0,1)):$$POINT^DG1010P0(DGP(DGI),5,5,2),1:$EXTRACT(X,1,18))
End DoDot:2
End DoDot:1
+6 IF (DGTMP=0)
SET DGD(.121,11)=""
WRADD WRITE !,"9A. STREET ADDRESS:",?21,DGD(.11,1),?66,"|"," 10A. STREET ADDRESS:",?89,DGD(.121,1)
+1 IF (DGDMAX>1)
WRITE !?21,DGD(.11,2),?66,"|",?89,DGD(.121,2)
+2 IF (DGDMAX>2)
WRITE !?21,DGD(.11,3),?66,"|",?89,DGD(.121,3)
+3 WRITE !,DGL2
+4 WRITE !,"9B. CITY: ",DGD(.11,4),?33,"| ","9C. STATE: ",DGD(.11,5),?66,"|"," 10B. CITY: ",$EXTRACT(DGD(.121,4),1,20),?99,"| ","10C. STATE: ",DGD(.121,5),!,DGL2
+5 WRITE !,"9D. ZIP CODE: ",DGD(.11,12),?33,"| ","9E. COUNTY: ",$$POINT^DG1010P0(DGP(.11),7,("^DIC(5,"_+$PIECE(DGP(.11),U,5)_",1,"),0),?66,"| "
+6 WRITE "10D. ZIP CODE: ",DGD(.121,12),?99,"| ","10E. COUNTY: "
+7 IF (DGTMP=1)
WRITE $$POINT^DG1010P0(DGP(.121),11,("^DIC(5,"_+$PIECE(DGP(.121),U,5)_",1,"),0)
+8 WRITE !,DGL2
+9 WRITE !,"9F. HOME TELEPHONE NUMBER: ",$$DISP^DG1010P0(DGP(.13),1),?66,"| ","10F. HOME TELEPHONE NUMBER:",?96
+10 IF DGTMP
WRITE $$DISP^DG1010P0(DGP(.121),10)
+11 WRITE !,DGLUND
CA ;Display confidential address information
+1 NEW DGACT,DGCAT,DGCATN,DGCATS,VAPA
+2 DO ADD^VADPT
+3 WRITE !,"11. CONFIDENTIAL ADDRESS",?66,"|"
+4 IF VAPA(12)=""!(VAPA(12)=0)
Begin DoDot:1
+5 WRITE !?11,"Not Applicable",?66,"|"
+6 WRITE !,DGLUND
End DoDot:1
GOTO SEX
+7 WRITE !,DGL2
+8 WRITE !,"11A. STREET ADDRESS:",?21,VAPA(13)
+9 WRITE ?66,"| ","11B. CITY: ",$EXTRACT(VAPA(16),0,19),?99,"| 11C. STATE: ",$PIECE(VAPA(17),"^",2)
+10 WRITE !,?21,VAPA(14)
+11 WRITE ?66,"| ","11D. ZIP CODE: ",$PIECE(VAPA(18),"^",2),?99,"| 11E. COUNTY: ",$PIECE(VAPA(19),"^",2)
+12 WRITE !,?21,VAPA(15),?66,"| 11F. START DATE: ",$PIECE(VAPA(20),"^",2),?99,"| STOP DATE: ",$PIECE(VAPA(21),"^",2)
+13 WRITE !,$EXTRACT(DGL2,1,99),"|",$EXTRACT(DGL2,1,32)
+14 WRITE !,"11G. Active Confidential Address Categories",?66,"|"
+15 SET DGCATS=""
FOR
SET DGCATS=$ORDER(VAPA(22,DGCATS))
IF DGCATS=""
QUIT
Begin DoDot:1
+16 SET DGCAT=VAPA(22,DGCATS)
SET DGACT=$PIECE(DGCAT,"^",3)
SET DGCATN=$PIECE(DGCAT,"^",2)
+17 IF DGACT="Y"
WRITE !?11,DGCATN,?66,"|"
End DoDot:1
+18 WRITE !,DGLUND
SEX KILL DGD,DGX
+1 WRITE !,"12. PATIENT'S SEX",?33,"| ","13. MOTHER'S MAIDEN NAME",?66,"| ","14. MOTHER'S NAME",?99,"| ","15. FATHER'S NAME"
+2 SET X=$PIECE(DGP(0),U,2)
WRITE !?5,$SELECT((X="M"):"MALE",(X="F"):"FEMALE",1:"UNANSWERED")
+3 WRITE ?33,"| ",?40,$EXTRACT(($$DISP^DG1010P0(DGP(.24),3)),1,25),?66,"| ",?73,$EXTRACT(($$DISP^DG1010P0(DGP(.24),2)),1,23),?99,"| ",?106,$EXTRACT(($$DISP^DG1010P0(DGP(.24),1)),1,30),?131,$CHAR(13),DGLUND
RELIG ;
+1 WRITE !,"16. RELIGIOUS PREFERENCE",?33,"| ","17. DATE OF PREVIOUS CARE",?66,"| ","18. LOCATION OF PREVIOUS CARE",?99,"| ","19. SPINAL CORD INJURY"
+2 WRITE !?5,$$POINT^DG1010P0(DGP(0),8,13),?33,"| ",?40,$$DATENP^DG1010P0(DGP(1010.15),1),?66,"| ",?73,$$POINT^DG1010P0(DGP(1010.15),2,4)
+3 SET X=$$UNK^DG1010P0($PIECE(DGP(57),U,4))
+4 WRITE ?99,"| ",?106,$SELECT((DGUNK):X,(X=1):"PARAPLEGIA-TRAUMATIC",(X=2):"QUADRIPLEGIA-TRAUMATIC",(X=3):"PARAPLEGIA-NONTRAUMATIC",(X=4):"QUADRIPLEGIA-NONTRAUMATIC",(X="X"):"NOT APPLICABLE",1:"INVALID"),?131,$CHAR(13),DGLUND,!
CONTD ;
+1 GOTO CONT^DG1010P2
+2 ;
