Routine: DGRPTP3

Package	Total	Caller Graph
Registration	1	DGRPTP2

Name	Comments	DBIA/ICR reference
EN(DGLNE)	;Entry point to print 10-10T cont. ; Input -- DGLNE Line format array ; Output -- None

Name	Line Occurrences
Function Call: WRITE	Prompt: !,"Consent To Release Information: I hereby authorize the Department of Veterans Affairs to disclose any such history, diagnostic and" Line Location: EN+5
Function Call: WRITE	Prompt: !,"treatment information from my medical records (including information relating to the diagnosis, treatment or other therapy for the" Line Location: EN+6
Function Call: WRITE	Prompt: !,"conditions of drug abuse, alcoholism or alcohol abuse, sickle cell anemia, or testing for or infection with the human" Line Location: EN+7
Function Call: WRITE	Prompt: !,"immunodeficiency virus) to the carrier or contractor of any health plan contract under which I am apparently entitled to medical" Line Location: EN+8
Function Call: WRITE	Prompt: !,"care or payment of the expense of care that is identified above, as considered necessary by VA representatives for the discharge" Line Location: EN+9
Function Call: WRITE	Prompt: !,"of the legal or contractual obligations of the insurer or other party against whom liability is asserted. I understand that I" Line Location: EN+10
Function Call: WRITE	Prompt: !,"may revoke this authorization at any time, except to the extent that action has already been taken in reliance on it. Without my" Line Location: EN+11
Function Call: WRITE	Prompt: !,"express revocation, this consent will automatically expire when all action arising from VA's claim for reimbursement for my" Line Location: EN+12
Function Call: WRITE	Prompt: !,"medical care has been completed." Line Location: EN+13
Function Call: WRITE	Prompt: ?131,$C(13) Line Location: EN+14
Function Call: WRITE	Prompt: ! Condition for execution: DGLNE("ULC")="-" Line Location: EN+14
Function Call: WRITE	Prompt: DGLNE("UL") Line Location: EN+14
Function Call: WRITE	Prompt: !,"Co-payment Notice: If your household income exceeds the established threshold, you will be considered ""Discretionary""." Line Location: EN+17
Function Call: WRITE	Prompt: !,"Such veterans must pay a co-payment not to exceed the Medicare deductible, plus a per diem for hospital and nursing care." Line Location: EN+18
Function Call: WRITE	Prompt: !,"By signing this application, you are agreeing to pay the VA the applicable co-payment if you are determined to be a" Line Location: EN+19
Function Call: WRITE	Prompt: !,"""discretionary"" veteran." Line Location: EN+20
Function Call: WRITE	Prompt: ?131,$C(13) Line Location: EN+21
Function Call: WRITE	Prompt: ! Condition for execution: DGLNE("ULC")="-" Line Location: EN+21
Function Call: WRITE	Prompt: DGLNE("UL") Line Location: EN+21
Function Call: WRITE	Prompt: !,"Signature of Applicant",?95,"\|Date" Line Location: EN+24
Function Call: WRITE	Prompt: !?95,"\|" Line Location: EN+25
Function Call: WRITE	Prompt: !?95,"\|" Line Location: EN+26
Function Call: WRITE	Prompt: !,DGLNE("DD") Line Location: EN+27
Function Call: WRITE	Prompt: !,"Public reporting burden for this collection of information is estimated to average 10 minutes per response, including the time for" Line Location: EN+30
Function Call: WRITE	Prompt: !,"reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the" Line Location: EN+31
Function Call: WRITE	Prompt: !,"collection of information. Send comments regarding this burden estimate or any other aspects of this collection, including" Line Location: EN+32
Function Call: WRITE	Prompt: !,"suggestions for reducing this burden to VA Clearance Officer (045A4), 810 Vermont Avenue, NW, Washington, DC 20420." Line Location: EN+33
Function Call: WRITE	Prompt: !,DGLNE("DD") Line Location: EN+34
Function Call: WRITE	Prompt: !,"PRIVACY ACT NOTICE: The information requested on this form is solicited under authority of Title 38, U.S.C., Sections 710, 1712" Line Location: EN+37
Function Call: WRITE	Prompt: !,"and 1722. It is being collected to enable us to determine your eligibility for medical benefits, identify your medical records," Line Location: EN+38
Function Call: WRITE	Prompt: !,"and provide basic data for your treatment. Additional information, such as medical history, may be solicited during the course of" Line Location: EN+39
Function Call: WRITE	Prompt: !,"your medical evaluation or treatment. The income and eligibility information you supply may be verified through a computer" Line Location: EN+40
Function Call: WRITE	Prompt: !,"matching program at any time and information may be disclosed outside VA as permitted by law; possible disclosures include" Line Location: EN+41
Function Call: WRITE	Prompt: !,"those described in the ""routine uses"" identified in the VA system of records 24VA136, Patient Medical Records-VA, published" Line Location: EN+42
Function Call: WRITE	Prompt: !,"in the Federal Register in accordance with the Privacy Act of 1974. These ""routine uses"" include disclosures: in response" Line Location: EN+43
Function Call: WRITE	Prompt: !,"to court subpoenas; to epidemiological and other research facilities for research purposes; in connection with collections" Line Location: EN+44
Function Call: WRITE	Prompt: !,"of amounts owed to the United States; to the Department of Justice for use in litigation; to other Federal agencies in connection" Line Location: EN+45
Function Call: WRITE	Prompt: !,"with their employment determinations, investigations, or issuance of licenses or benefits; to report apparent law violations to" Line Location: EN+46
Function Call: WRITE	Prompt: !,"other Federal, State or local agencies charged with law enforcement responsibilities; in response to an official request from a" Line Location: EN+47
Function Call: WRITE	Prompt: !,"criminal or civil law enforcement governmental agency charged with the protection of public health or safety; to the Internal" Line Location: EN+48
Function Call: WRITE	Prompt: !,"Revenue Service to verify unearned income, collect amounts owed VA, and to report as income debts that are waived, compromised or" Line Location: EN+49
Function Call: WRITE	Prompt: !,"otherwise forgiven; to the Social Security Administration to verify earned income and employment data; to notify State licensing" Line Location: EN+50
Function Call: WRITE	Prompt: !,"boards and Federal agencies of the health care practices of health care providers; to non-VA health care providers; to non-VA" Line Location: EN+51
Function Call: WRITE	Prompt: !,"health care providers of facilities when the patient is referred for medical care at VA expense; to private sector organizations" Line Location: EN+52
Function Call: WRITE	Prompt: !,"for the purpose of obtaining accreditation or approval rating for the health care facility; to non-VA nursing homes for" Line Location: EN+53
Function Call: WRITE	Prompt: !,"preadmission screening; or, to contractors to perform the services covered by the contract. Disclosure is voluntary, however," Line Location: EN+54
Function Call: WRITE	Prompt: !,"failure to furnish the information will result in our inability to process your request and serve your medical needs." Line Location: EN+55
Function Call: WRITE	Prompt: !,"Failure to furnish the information will have no adverse effect on any other benefits to which you may be entitled." Line Location: EN+56
Function Call: WRITE	Prompt: !,"Disclosure of the Social Security number(s) of those for whom benefits are claimed is requested under the authority of" Line Location: EN+57
Function Call: WRITE	Prompt: !,"Title 38, U.S.C., and is voluntary. Social Security numbers will be used in the administration of veteran's benefits," Line Location: EN+58
Function Call: WRITE	Prompt: !,"in the identification of veterans or persons claiming or receiving VA benefits and their records and may be used for" Line Location: EN+59
Function Call: WRITE	Prompt: !,"other purposes where authorized by both Title 38, U.S.C., and the Privacy Act of 1974 (5 U.S.C. 552a) or where" Line Location: EN+60
Function Call: WRITE	Prompt: !,"required by another statute." Line Location: EN+61

>>	Not killed explicitly
*	Changed
!	Killed
~	Newed

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Package: Registration

Routine: DGRPTP3

Information

Source Information

Caller Graph

Caller Graph Total: 1

Entry Points

Interaction Calls

Local Variables

Legend:

Name	Field # of Occurrence
DGLNE	EN~
DGLNE("DD"	EN+27, EN+34
DGLNE("UL"	EN+14, EN+21
DGLNE("ULC"	EN+14, EN+21