- DGRPTP3 ;ALB/RMO - Print 10-10T Registration Cont.;10 JAN 1997 09:06 am
- ;;5.3;Registration;**108**;08/13/93
- ;
- EN(DGLNE) ;Entry point to print 10-10T cont.
- ; Input -- DGLNE Line format array
- ; Output -- None
- ;
- ;Consent to release information
- W !,"Consent To Release Information: I hereby authorize the Department of Veterans Affairs to disclose any such history, diagnostic and"
- W !,"treatment information from my medical records (including information relating to the diagnosis, treatment or other therapy for the"
- W !,"conditions of drug abuse, alcoholism or alcohol abuse, sickle cell anemia, or testing for or infection with the human"
- W !,"immunodeficiency virus) to the carrier or contractor of any health plan contract under which I am apparently entitled to medical"
- W !,"care or payment of the expense of care that is identified above, as considered necessary by VA representatives for the discharge"
- W !,"of the legal or contractual obligations of the insurer or other party against whom liability is asserted. I understand that I"
- W !,"may revoke this authorization at any time, except to the extent that action has already been taken in reliance on it. Without my"
- W !,"express revocation, this consent will automatically expire when all action arising from VA's claim for reimbursement for my"
- W !,"medical care has been completed."
- W ?131,$C(13) W:DGLNE("ULC")="-" ! W DGLNE("UL")
- ;
- ;Co-payment notice
- W !,"Co-payment Notice: If your household income exceeds the established threshold, you will be considered ""Discretionary""."
- W !,"Such veterans must pay a co-payment not to exceed the Medicare deductible, plus a per diem for hospital and nursing care."
- W !,"By signing this application, you are agreeing to pay the VA the applicable co-payment if you are determined to be a"
- W !,"""discretionary"" veteran."
- W ?131,$C(13) W:DGLNE("ULC")="-" ! W DGLNE("UL")
- ;
- ;Signature block and date
- W !,"Signature of Applicant",?95,"|Date"
- W !?95,"|"
- W !?95,"|"
- W !,DGLNE("DD")
- ;
- ;Public reporting burden
- W !,"Public reporting burden for this collection of information is estimated to average 10 minutes per response, including the time for"
- W !,"reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the"
- W !,"collection of information. Send comments regarding this burden estimate or any other aspects of this collection, including"
- W !,"suggestions for reducing this burden to VA Clearance Officer (045A4), 810 Vermont Avenue, NW, Washington, DC 20420."
- W !,DGLNE("DD")
- ;
- ;Privacy act notice
- W !,"PRIVACY ACT NOTICE: The information requested on this form is solicited under authority of Title 38, U.S.C., Sections 710, 1712"
- W !,"and 1722. It is being collected to enable us to determine your eligibility for medical benefits, identify your medical records,"
- W !,"and provide basic data for your treatment. Additional information, such as medical history, may be solicited during the course of"
- W !,"your medical evaluation or treatment. The income and eligibility information you supply may be verified through a computer"
- W !,"matching program at any time and information may be disclosed outside VA as permitted by law; possible disclosures include"
- W !,"those described in the ""routine uses"" identified in the VA system of records 24VA136, Patient Medical Records-VA, published"
- W !,"in the Federal Register in accordance with the Privacy Act of 1974. These ""routine uses"" include disclosures: in response"
- W !,"to court subpoenas; to epidemiological and other research facilities for research purposes; in connection with collections"
- W !,"of amounts owed to the United States; to the Department of Justice for use in litigation; to other Federal agencies in connection"
- W !,"with their employment determinations, investigations, or issuance of licenses or benefits; to report apparent law violations to"
- W !,"other Federal, State or local agencies charged with law enforcement responsibilities; in response to an official request from a"
- W !,"criminal or civil law enforcement governmental agency charged with the protection of public health or safety; to the Internal"
- W !,"Revenue Service to verify unearned income, collect amounts owed VA, and to report as income debts that are waived, compromised or"
- W !,"otherwise forgiven; to the Social Security Administration to verify earned income and employment data; to notify State licensing"
- W !,"boards and Federal agencies of the health care practices of health care providers; to non-VA health care providers; to non-VA"
- W !,"health care providers of facilities when the patient is referred for medical care at VA expense; to private sector organizations"
- W !,"for the purpose of obtaining accreditation or approval rating for the health care facility; to non-VA nursing homes for"
- W !,"preadmission screening; or, to contractors to perform the services covered by the contract. Disclosure is voluntary, however,"
- W !,"failure to furnish the information will result in our inability to process your request and serve your medical needs."
- W !,"Failure to furnish the information will have no adverse effect on any other benefits to which you may be entitled."
- W !,"Disclosure of the Social Security number(s) of those for whom benefits are claimed is requested under the authority of"
- W !,"Title 38, U.S.C., and is voluntary. Social Security numbers will be used in the administration of veteran's benefits,"
- W !,"in the identification of veterans or persons claiming or receiving VA benefits and their records and may be used for"
- W !,"other purposes where authorized by both Title 38, U.S.C., and the Privacy Act of 1974 (5 U.S.C. 552a) or where"
- W !,"required by another statute."
- Q
- DGRPTP3 ;ALB/RMO - Print 10-10T Registration Cont.;10 JAN 1997 09:06 am
- +1 ;;5.3;Registration;**108**;08/13/93
- +2 ;
- EN(DGLNE) ;Entry point to print 10-10T cont.
- +1 ; Input -- DGLNE Line format array
- +2 ; Output -- None
- +3 ;
- +4 ;Consent to release information
- +5 WRITE !,"Consent To Release Information: I hereby authorize the Department of Veterans Affairs to disclose any such history, diagnostic and"
- +6 WRITE !,"treatment information from my medical records (including information relating to the diagnosis, treatment or other therapy for the"
- +7 WRITE !,"conditions of drug abuse, alcoholism or alcohol abuse, sickle cell anemia, or testing for or infection with the human"
- +8 WRITE !,"immunodeficiency virus) to the carrier or contractor of any health plan contract under which I am apparently entitled to medical"
- +9 WRITE !,"care or payment of the expense of care that is identified above, as considered necessary by VA representatives for the discharge"
- +10 WRITE !,"of the legal or contractual obligations of the insurer or other party against whom liability is asserted. I understand that I"
- +11 WRITE !,"may revoke this authorization at any time, except to the extent that action has already been taken in reliance on it. Without my"
- +12 WRITE !,"express revocation, this consent will automatically expire when all action arising from VA's claim for reimbursement for my"
- +13 WRITE !,"medical care has been completed."
- +14 WRITE ?131,$CHAR(13)
- IF DGLNE("ULC")="-"
- WRITE !
- WRITE DGLNE("UL")
- +15 ;
- +16 ;Co-payment notice
- +17 WRITE !,"Co-payment Notice: If your household income exceeds the established threshold, you will be considered ""Discretionary""."
- +18 WRITE !,"Such veterans must pay a co-payment not to exceed the Medicare deductible, plus a per diem for hospital and nursing care."
- +19 WRITE !,"By signing this application, you are agreeing to pay the VA the applicable co-payment if you are determined to be a"
- +20 WRITE !,"""discretionary"" veteran."
- +21 WRITE ?131,$CHAR(13)
- IF DGLNE("ULC")="-"
- WRITE !
- WRITE DGLNE("UL")
- +22 ;
- +23 ;Signature block and date
- +24 WRITE !,"Signature of Applicant",?95,"|Date"
- +25 WRITE !?95,"|"
- +26 WRITE !?95,"|"
- +27 WRITE !,DGLNE("DD")
- +28 ;
- +29 ;Public reporting burden
- +30 WRITE !,"Public reporting burden for this collection of information is estimated to average 10 minutes per response, including the time for"
- +31 WRITE !,"reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the"
- +32 WRITE !,"collection of information. Send comments regarding this burden estimate or any other aspects of this collection, including"
- +33 WRITE !,"suggestions for reducing this burden to VA Clearance Officer (045A4), 810 Vermont Avenue, NW, Washington, DC 20420."
- +34 WRITE !,DGLNE("DD")
- +35 ;
- +36 ;Privacy act notice
- +37 WRITE !,"PRIVACY ACT NOTICE: The information requested on this form is solicited under authority of Title 38, U.S.C., Sections 710, 1712"
- +38 WRITE !,"and 1722. It is being collected to enable us to determine your eligibility for medical benefits, identify your medical records,"
- +39 WRITE !,"and provide basic data for your treatment. Additional information, such as medical history, may be solicited during the course of"
- +40 WRITE !,"your medical evaluation or treatment. The income and eligibility information you supply may be verified through a computer"
- +41 WRITE !,"matching program at any time and information may be disclosed outside VA as permitted by law; possible disclosures include"
- +42 WRITE !,"those described in the ""routine uses"" identified in the VA system of records 24VA136, Patient Medical Records-VA, published"
- +43 WRITE !,"in the Federal Register in accordance with the Privacy Act of 1974. These ""routine uses"" include disclosures: in response"
- +44 WRITE !,"to court subpoenas; to epidemiological and other research facilities for research purposes; in connection with collections"
- +45 WRITE !,"of amounts owed to the United States; to the Department of Justice for use in litigation; to other Federal agencies in connection"
- +46 WRITE !,"with their employment determinations, investigations, or issuance of licenses or benefits; to report apparent law violations to"
- +47 WRITE !,"other Federal, State or local agencies charged with law enforcement responsibilities; in response to an official request from a"
- +48 WRITE !,"criminal or civil law enforcement governmental agency charged with the protection of public health or safety; to the Internal"
- +49 WRITE !,"Revenue Service to verify unearned income, collect amounts owed VA, and to report as income debts that are waived, compromised or"
- +50 WRITE !,"otherwise forgiven; to the Social Security Administration to verify earned income and employment data; to notify State licensing"
- +51 WRITE !,"boards and Federal agencies of the health care practices of health care providers; to non-VA health care providers; to non-VA"
- +52 WRITE !,"health care providers of facilities when the patient is referred for medical care at VA expense; to private sector organizations"
- +53 WRITE !,"for the purpose of obtaining accreditation or approval rating for the health care facility; to non-VA nursing homes for"
- +54 WRITE !,"preadmission screening; or, to contractors to perform the services covered by the contract. Disclosure is voluntary, however,"
- +55 WRITE !,"failure to furnish the information will result in our inability to process your request and serve your medical needs."
- +56 WRITE !,"Failure to furnish the information will have no adverse effect on any other benefits to which you may be entitled."
- +57 WRITE !,"Disclosure of the Social Security number(s) of those for whom benefits are claimed is requested under the authority of"
- +58 WRITE !,"Title 38, U.S.C., and is voluntary. Social Security numbers will be used in the administration of veteran's benefits,"
- +59 WRITE !,"in the identification of veterans or persons claiming or receiving VA benefits and their records and may be used for"
- +60 WRITE !,"other purposes where authorized by both Title 38, U.S.C., and the Privacy Act of 1974 (5 U.S.C. 552a) or where"
- +61 WRITE !,"required by another statute."
- +62 QUIT
