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
