

GTM>[?1h=D[C [C^[CZ[CU[C[?1l>
NEW SYSTEM 304-262-7078



Volume set: PLA:GTM  UCI: PLA  Device: /dev/pts/3

ACCESS CODE: ********
VERIFY CODE: ********

Good afternoon ALEXANDER,ROBERT
     You last signed on today at 15:11[c
Select TERMINAL TYPE NAME: C-VT320//     
          Digital Equipment Corporation VT-320 video

Select Core Applications Option: ADT MANAGER MENU


        ***************** CPT COPYRIGHT NOTICE ****************** 
   Any five-digit numeric Physician's Current Procedural Terminology, Fourth
Edition (CPT-4) codes, service description, instructions and/or guidelines only
are Copyright 1988 (or such other date of publication of CPT-4 as defined in
the Berne Implementation Act of 1988 formerly the Copyright Revision Act of
1976) American Medical Association.  
   No fee schedules, basic unit values, relative value guides or related 
listings are included in CPT-4. The AMA assumes no responsibility for the 
consequences attributable to or related to any use or interpretation of 
information contained in or not contained in this publication. The AMA shall
not be deemed to be engaged in the practice of medicine or dispensing medical
services.  
                        
Printing of any CPT information that will be released external to the VA 
(excluding areas of billing/fee basis processing, administrative management, 
clinical management including research, and patient coding/summarizing) must
include the following notice: "CPT five-digit codes and/or descriptions only
are copyright 1988 AMA (or such other date or publication of the work as
defined in the Berne Implementation Act of 1988, formerly the Copyright 
Revision Act of 1976)." 

Press any key to continue[3;1H[1;1H[J[2J[H
Hi.  Welcome to MAS, VERSION 5.3
= = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = 
AMIS 401-420 Reports ............... Last run for month of 
Auto Recalculation ................. Last run  on CPU 
                   ................. Scheduled for APR 01, 2013@21:00
Embosser Option from Registration .. Is turned OFF
Gains & Losses (G&L) ............... Last run 
HINQ Option from Registration ...... Is turned OFF
RUG-II Background Job .............. Last run 
Appointment Status Update .......... Last run 
                          .......... Updated appointments for 
                          .......... Scheduled for (not currently scheduled)
IRT Background Job ................. Last run 
                   ................. Scheduled for (not currently scheduled)

YOU ARE PRESENTLY ON CPU PLA,PLA



Select ADT Manager Menu Option: veteran id card menu

Select Veteran ID Card Menu Option: single patient download requestuest

Select PATIENT NAME: 323554567  TWENTYFOUR,PATIENT X        3-2-48    323554567 
    YES     SC VETERAN      
 - ELIGIBILITY CODE MISSING
 - PERIOD OF SERVICE MISSING
 - CLAIM NUMBER MISSING
 - MARITAL STATUS MISSING
 - RELIGIOUS PREFERENCE MISSING
 - ADDRESS DATA MISSING
Do you still wish to download data ? No// yes  (Yes)	 S DGIEN=+$P($Q(^DGMS(29.11,"APDT",DFN,DGDATE,DGIEN),-1),",",5)
	                                                    ^-----
		At column 53, line 45, source module /home/softhat/VistA-Instance/r/DGMSTAPI.m
%GTM-E-RPARENMISSING, Right parenthesis expected

Data Download successfully to VIC

Select PATIENT NAME: 

Select Veteran ID Card Menu Option: Problem List Mgt Menu

Select Problem List Mgt Menu Option: Patient Problem List
Select PATIENT NAME: 323554567  TWENTYFOUR,PATIENT X        3-2-48    323554567 
    YES     SC VETERAN      
Searching for the patient's problem list ...
[?25l
[1;1H[1;1H[J[2J[H
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[1;1HPROBLEM LIST[22m[4m                  
[1;31HApr 01, 2013@15:12:12          Page:    1 of    0 [24m[1;1H
TWENTYFOUR,PATIENT X  (T4567)                                 0 active problems
                                 ACTIVE PROBLEMS
[3;1H
[4m
     Problem                                   Updated Clinic                   
[24m

[4;1H
                                                                                
    No data available meeting criteria.                                         








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[16;1H[J7[16;24r8
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7[1;31HApr 01, 2013@15:12:128
[24m
[15;1H[14;1H

AD  Add New Problems      IN  (Inactivate Problems) VW  Select View of List
RM  (Remove Problems)     CM  (Comment on a Problem)SP  Select New Patient
ED  (Edit a Problem)      DT  (Detailed Display)    PP  Print Problem List
                          $   (Verify Problems)     Q   Quit[J
[?25h

Select Action: Add New Problems// Quit   Quit  7[1;24r8[m[m[6;1H[1;1H[J[2J[H

Select Problem List Mgt Menu Option: 

Select Veteran ID Card Menu Option: 

Select ADT Manager Menu Option: ADT Outputs Menu

Select ADT Outputs Menu Option: 10-10 Print


Select PATIENT NAME: 323554567  TWENTYFOUR,PATIENT X        3-2-48    323554567 
    YES     SC VETERAN      
PRINT 10-10EZ? YES// yes  YES

     This output requires 132 column output to a PRINTER.
     Output to SCREEN will be unreadable.

DEVICE: HOME// HOME  TELNET
[1;1H[1;1H[J[2J[H                                                                                                   OMB APPROVED NO. 2900-0091
                                                                                                       Estimated Burden Avg. 45 min.
                                                                                                           Expiration Date 6/30/2007
====================================================================================================================================
D E P A R T M E N T   O F   V E T E R A N S   A F F A I R S                     APPLICATION FOR HEALTH BENEFITS
====================================================================================================================================

                                                  SECTION I - GENERAL INFORMATION                                                  

------------------------------------------------------------------------------------------------------------------------------------
                  Federal law provides criminal penalties, including a fine and/or imprisonment for up to 5 years,
                    for concealing a material fact or making a materially false statement.  (See 18 U.S.C. 1001)                   

------------------------------------------------------------------------------------------------------------------------------------
1. VETERAN'S NAME (Last, First, Middle Name)      |2. OTHER NAMES USED                 |3. MOTHER'S MAIDEN NAME
   TWENTYFOUR,PATIENT X                           |                                    |   ZEBRA                                   

------------------------------------------------------------------------------------------------------------------------------------
4. GENDER       |5. WHAT IS YOUR RACE?   ___AMERICAN INDIAN OR ALASKA NATIVE              ___ASIAN     ___BLACK OR AFRICAN AMERICAN
   MALE         |                        ___NATIVE HAWAIIAN OR OTHER PACIFIC ISLANDER     ___WHITE     ___UNKNOWN BY PATIENT       

------------------------------------------------------------------------------------------------------------------------------------
6. ARE YOU SPANISH, HISPANIC,    |7. SOCIAL SECURITY NUMBER   |9. DATE OF BIRTH (mm/dd/yyyy)   |10. RELIGION
   OR LATINO?                    |   323-55-4567              |   03/02/1948                   |                                   

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8. CLAIM NUMBER                                                   |9A. PLACE OF BIRTH (City & State)
                                                                  |    Trenton, NEW JERSEY                                         

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11. PERMANENT ADDRESS (Street)           |11A. CITY             |11B. PROVINCE                             |11C. POSTAL CODE
                                         |                      |                                          |                       

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11D. COUNTRY                       |11E. HOME TELEPHONE NUMBER (Include area code)  |11F. E-MAIL ADDRESS
                                   |                                                |                                              

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11G. CELLULAR TELEPHONE NUMBER (Include area code)                |11H. PAGER NUMBER (Include area code)
                                                                  |                                                                

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12. TYPE OF BENEFIT(S) APPLIED FOR:
    UNKNOWN                                                                                                                        

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13. IF APPLYING FOR HEALTH SERVICES OR ENROLLMENT, WHICH VA MEDICAL CENTER   |14. HAVE YOU BEEN SEEN AT A VA HEALTH CARE FACILITY?
    OR OUTPATIENT CLINIC DO YOU PREFER?  UNKNOWN                             |                                                     

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15. DO YOU WANT AN APPOINTMENT WITH A VA DOCTOR OR PROVIDER AS SOON AS ONE BECOMES     |16. CURRENT MARITAL STATUS
    AVAILABLE?                                                                         |                                           

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17. NAME, ADDRESS AND RELATIONSHIP OF NEXT OF KIN                                  |17A. NEXT OF KIN'S HOME TELEPHONE NUMBER
     -                                                                             |     (Include area code)                       

                                                                                    ------------------------------------------------
                                                                                   |17B. NEXT OF KIN'S WORK TELEPHONE NUMBER
                                                                                   |     (Include area code)                       

------------------------------------------------------------------------------------------------------------------------------------
18. NAME, ADDRESS AND RELATIONSHIP OF EMERGENCY CONTACT                            |18A. EMERGENCY CONTACT'S HOME TELEPHONE NUMBER
     -                                                                             |     (Include area code)                       

                                                                                    ------------------------------------------------
                                                                                   |18B. EMERGENCY CONTACT'S WORK TELEPHONE NUMBER
                                                                                   |     (Include area code)                       

------------------------------------------------------------------------------------------------------------------------------------
19. INDIVIDUAL TO RECEIVE POSSESSION OF YOUR PERSONAL PROPERTY LEFT ON PREMISES UNDER VA CONTROL AFTER YOUR DEPARTURE OR AT THE
    THE TIME OF DEATH  (NOTE: THIS DOES NOT CONSTITUTE A WILL OR TRANSFER OF TITLE):                                               

------------------------------------------------------------------------------------------------------------------------------------
====================================================================================================================================
VA FORM 10-10EZ FEB 2005                PRINTED: Apr 01, 2013@15:12:13          Clerk: RA/                              PAGE 1[11;1H[1;1H[J[2J[HAPPLICATION FOR HEALTH BENEFITS, Continued      | VETERAN'S NAME (Last, First, Middle)             | SOCIAL SECURITY NUMBER
                                                       | TWENTYFOUR,PATIENT X                             | 323-55-4567            

------------------------------------------------------------------------------------------------------------------------------------

                         SECTION II - INSURANCE INFORMATION  (Use Separate Sheet for Additional Insurance)                         

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1. ARE YOU COVERED BY HEALTH INSURANCE?          |2. HEALTH INSURANCE COMPANY NAME, ADDRESS AND TELEPHONE NUMBER
   (Including coverage through a spouse          |   
   or another person)   UNKNOWN                  |                                                                                 

-------------------------------------------------
3. NAME OF POLICY HOLDER                         |    
                                                 |                                                                                 

------------------------------------------------------------------------------------------------------------------------------------
4. POLICY NUMBER                                 |5. GROUP CODE                      |6. ARE YOU ELIGIBLE FOR MEDICAID?
                                                 |                                   |                                             

------------------------------------------------------------------------------------------------------------------------------------
7. ARE YOU ENROLLED IN MEDICARE HOSPITAL INSURANCE PART A?                 |7A. EFFECTIVE DATE (mm/dd/yyyy)                        

------------------------------------------------------------------------------------------------------------------------------------
8. ARE YOU ENROLLED IN MEDICARE HOSPITAL INSURANCE PART B?                 |8A. EFFECTIVE DATE (mm/dd/yyyy)                        

------------------------------------------------------------------------------------------------------------------------------------
9. NAME EXACTLY AS IT APPEARS ON YOUR MEDICARE CARD                   |10. MEDICARE CLAIM NUMBER
                                                                      |                                                            

------------------------------------------------------------------------------------------------------------------------------------
11. IS NEED FOR CARE DUE TO ON THE JOB INJURY?  UNKNOWN               |12. IS NEED FOR CARE DUE TO ACCIDENT?  UNKNOWN              

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                                                SECTION III - EMPLOYMENT INFORMATION                                               

------------------------------------------------------------------------------------------------------------------------------------
1. VETERAN'S EMPLOYMENT STATUS                 |1A. COMPANY NAME, ADDRESS AND TELEPHONE NUMBER
                                               |       
Date of retirement (mm/dd/yyyy)                |    
If employed or retired, complete item 1A       |                                                                                   

------------------------------------------------------------------------------------------------------------------------------------
2. SPOUSE'S EMPLOYMENT STATUS                  |2A. COMPANY NAME, ADDRESS AND TELEPHONE NUMBER
                                               |       
Date of retirement (mm/dd/yyyy)                |    
If employed or retired, complete item 2A       |                                                                                   

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                                             SECTION IV - MILITARY SERVICE INFORMATION                                             

------------------------------------------------------------------------------------------------------------------------------------
1. LAST BRANCH OF SERVICE   |1A. LAST ENTRY DATE  |1B. LAST DISCHARGE DATE  |1C. DISCHARGE TYPE        |1D. MILITARY SERVICE NUMBER
                            |                     |                         |                          |                           

------------------------------------------------------------------------------------------------------------------------------------
2. ANSWER YES OR NO:                                                                                                               

------------------------------------------------------------------------------------------------------------------------------------
  A.  ARE YOU A PURPLE HEART AWARD RECIPIENT?             | UNK |  F. DO YOU NEED CARE OF CONDITIONS POTENTIALLY RELATED TO |      

----------------------------------------------------------------
  B.  ARE YOU A FORMER PRISONER OF WAR?                   |     |      SERVICE IN SOUTHWEST ASIA?                           |      

------------------------------------------------------------------------------------------------------------------------------------
  C.  DO YOU HAVE A VA SERVICE-CONNECTED RATING?          | YES |  G. WERE YOU EXPOSED TO AGENT ORANGE WHILE SERVING IN     |      

----------------------------------------------------------------
  C1. IF YES, WHAT IS YOUR RATED PERCENTAGE?              | %   |     VIETNAM?                                              |      

------------------------------------------------------------------------------------------------------------------------------------
  D.  DID YOU SERVE IN COMBAT AFTER 11/11/1998?           |     |  H. WERE YOU EXPOSED TO RADIATION WHILE IN THE MILITARY?  |      

------------------------------------------------------------------------------------------------------------------------------------
  E.  WAS YOUR DISCHARGE FROM MILITARY FOR A DISABILITY   |     |  I. DID YOU RECEIVE NOSE & THROAT RADIUM TREATMENTS       | UNK
      INCURRED OR AGGRAVATED IN THE LINE OF DUTY?         |     |     WHILE IN THE MILITARY?                                |      

------------------------------------------------------------------------------------------------------------------------------------
  E1. ARE YOU RECEIVING DISABILITY RETIREMENT PAY         |     |  J. DO YOU HAVE A SPINAL CORD INJURY?                     | UNK
      INSTEAD OF VA COMPENSATION?                         |     |                                                           |      

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                                  SECTION V - PAPERWORK REDUCTION ACT AND PRIVACY ACT INFORMATION                                  

------------------------------------------------------------------------------------------------------------------------------------
     The Paperwork Reduction Act of 1995 requires us to notify you that this information collection is in accordance with the
clearance requirements of section 3507 of the Paperwork Reduction Act of 1995.  We may not conduct or sponsor, and you are not
required to respond to, a collection of information unless it displays a valid OMB number.  We anticipate that the time expended by
all individuals who must complete this form will average 45 minutes.  This includes the time it will take to read instructions,
gather the necessary facts and fill out the form.
     Privacy Act Information:  VA is asking you to provide the information on this form under 38 U.S.C., sections 1705, 1710, 1712,
and 1722 in order for VA to determine your eligibility for medical benefits.  Information you supply may be verified through a
computer-matching program.  VA may disclose the information that you put on the form as permitted by law.  VA may make a "routine
use" disclosure of the information as outlined in the Privacy Act systems of records notices and in accordance with the VHA Notice
of Privacy Practices.  You do not have to provide the information to VA, but if you don't, VA may be unable to process your request
and serve your medical needs.  Failure to furnish the information will not have any affect on any other benefits to which you may
be entitled.  If you provide VA your Social Security Number, VA will use it to administer your VA benefits.  VA may also use this
information to identify veterans and persons claiming or receiving VA benefits and their records, and for other purposes authorized
or required by law.
                                                                                                                                   

------------------------------------------------------------------------------------------------------------------------------------
====================================================================================================================================
VA FORM 10-10EZ FEB 2005                PRINTED: Apr 01, 2013@15:12:13          Clerk: RA/                              PAGE 2[11;1H[1;1H[J[2J[HAPPLICATION FOR HEALTH BENEFITS, Continued      | VETERAN'S NAME (Last, First, Middle)             | SOCIAL SECURITY NUMBER
                                                       | TWENTYFOUR,PATIENT X                             | 323-55-4567            

------------------------------------------------------------------------------------------------------------------------------------

                                                  SECTION VI - FINANCIAL DISCLOSURE                                                

------------------------------------------------------------------------------------------------------------------------------------
Failure to disclose your previous year's financial information may affect your eligibility for health care benefits.  Your financial
information is used by VA to accurately determine if you should be responsible for copayments for office visits, pharmacy,
inpatient, nursing home and long term care, and for some veterans, priority for enrollment.  You are not required to provide this
information.  However, completing the financial dislosure section results in a more accurate determination of your eligibility for
health care services/benefits.

   ___ NO, I DO NOT WISH TO PROVIDE INFORMATION IN SECTIONS VII THROUGH X.  I understand that VA is currently not enrolling veterans
who decline to provide financial information unless other special eligibility factors exist.  However, if I am enrolled, I agree to
pay the applicable VA copayments.  (Sign and date the application in Section XII.)

   ___ YES, I WILL PROVIDE SPECIFIC INCOME AND/OR ASSET INFORMATION TO ESTABLISH MY ELIGIBILITY FOR CARE.  (Complete all sections
below that apply to you with last calendar year's information.  Sign and date the application in Section XII.)
                                                                                                                                   

------------------------------------------------------------------------------------------------------------------------------------

                        SECTION VII - DEPENDENT INFORMATION  (Use a separate sheet for additional dependents)                      

------------------------------------------------------------------------------------------------------------------------------------
1.  SPOUSE'S NAME (Last, First, Middle Name)                |2.  CHILD'S NAME (Last, First, Middle Name)
                                                            |                                                                      

------------------------------------------------------------------------------------------------------------------------------------
1A. SPOUSE'S MAIDEN NAME                                    |2A. CHILD'S RELATIONSHIP TO YOU
                                                            |                                                                      

------------------------------------------------------------------------------------------------------------------------------------
1B. SPOUSE'S SOCIAL SECURITY NUMBER                         |2B. CHILD'S SOCIAL SECURITY NUMBER    |2C. DATE CHILD BECAME YOUR
                                                            |                                      |    DEPENDENT                  

------------------------------------------------------------------------------------------------------------------------------------
1C. SPOUSE'S DATE OF BIRTH (mm/dd/yyyy)     |1D. DATE OF MARRIAGE (mm/dd/yyyy)      |2D. CHILD'S DATE OF BIRTH (mm/dd/yyyy)
                                            |                                       |                                              

------------------------------------------------------------------------------------------------------------------------------------
1E. SPOUSE'S ADDRESS AND TELEPHONE NUMBER (Street, City, State, ZIP)                |2E. WAS CHILD PREMANENTLY AND TOTALLY
                                                                                    |    DISABLED BEFORE THE AGE OF 18?            

                                                                                     -----------------------------------------------
                                                                                    |2F. IF CHILD IS BETWEEN 18 AND 23 YEARS
                                                                                    |    OF AGE, DID CHILD ATTEND SCHOOL LAST
                                                                                    |    CALENDAR YEAR?                            

------------------------------------------------------------------------------------------------------------------------------------
3. IF YOUR SPOUSE OR DEPENDENT CHILD DID NOT LIVE WITH YOU LAST  |2G. EXPENSES PAID BY YOUR DEPENDENT CHILD FOR COLLEGE, VOCATIONAL
   YEAR, ENTER THE AMOUNT YOU CONTRIBUTED TO THEIR SUPPORT       |    REHABILITATION OR TRAINING (e.g., tuition, books, materials)
      SPOUSE  $                    CHILD  $                      |       $                                                         

------------------------------------------------------------------------------------------------------------------------------------

                 SECTION VIII - PREVIOUS CALENDAR YEAR GROSS ANNUAL INCOME OF VETERAN, SPOUSE AND DEPENDENT CHILDREN
                              (Use a separate sheet for additional dependents' financial information)                              

------------------------------------------------------------------------------------------------------------------------------------
                                                                            VETERAN              SPOUSE              CHILD 1       

------------------------------------------------------------------------------------------------------------------------------------
1. GROSS ANNUAL INCOME FROM EMPLOYMENT (wages, bonuses, tips, etc.)  |  $                 |  $                |  $ 
EXCLUDING INCOME FROM YOUR FARM, RANCH, PROPERTY OR BUSINESS         |                    |                   |                    

------------------------------------------------------------------------------------------------------------------------------------
2. NET INCOME FROM YOUR FARM, RANCH, PROPERTY OR BUSINESS            |  $                 |  $                |  $                 

------------------------------------------------------------------------------------------------------------------------------------
3. LIST OTHER INCOME AMOUNTS (Social Security, compensation,         |  $                 |  $                |  $ 
pension, interest, dividends.  Exclude welfare)                      |                    |                   |                    

------------------------------------------------------------------------------------------------------------------------------------

                                      SECTION IX - PREVIOUS CALENDAR YEAR DEDUCTIBLE EXPENSES                                      

------------------------------------------------------------------------------------------------------------------------------------
1. TOTAL NON-REIMBURSED MEDICAL EXPENSES PAID BY YOU OR YOUR SPOUSE (e.g., payments for doctors, dentists,    |  $ 
medications, Medicare, health insurance, hospital and nursing home)  VA will calculate a deductible and the   |
net medical expenses you may claim.                                                                           |                    

------------------------------------------------------------------------------------------------------------------------------------
2. AMOUNT YOU PAID LAST CALENDAR YEAR FOR FUNERAL AND BURIAL EXPENSES FOR YOUR DECEASED SPOUSE OR DEPENDENT   |  $ 
CHILD  (Also enter spouse or child's information in Section VII.)                                             |                    

------------------------------------------------------------------------------------------------------------------------------------
3. AMOUNT YOU PAID LAST CALENDAR YEAR FOR YOUR COLLEGE OR VOCATIONAL EDUCATIONAL EXPENSES (e.g., tuition,     |  $ 
books, fees, materials)  DO NOT LIST YOUR DEPENDENT'S EDUCATIONAL EXPENSES                                    |                    

------------------------------------------------------------------------------------------------------------------------------------
====================================================================================================================================
VA FORM 10-10EZ FEB 2005                PRINTED: Apr 01, 2013@15:12:13          Clerk: RA/                              PAGE 3[3;1H[1;1H[J[2J[HAPPLICATION FOR HEALTH BENEFITS, Continued      | VETERAN'S NAME (Last, First, Middle)             | SOCIAL SECURITY NUMBER
                                                       | TWENTYFOUR,PATIENT X                             | 323-55-4567            

------------------------------------------------------------------------------------------------------------------------------------

                  SECTION X - PREVIOUS CALENDAR YEAR NET WORTH  (Use a separate sheet for additional dependents)                   

------------------------------------------------------------------------------------------------------------------------------------
                                                                              |     VETERAN     |     SPOUSE      |     CHILD 1    

------------------------------------------------------------------------------------------------------------------------------------
1. CASH, AMOUNT IN BANK ACCOUNTS (e.g., checking and savings accounts,        |  $              |  $              |
certificates of deposit, individual retirement accounts, stocks and bonds)    |                 |                 |                

------------------------------------------------------------------------------------------------------------------------------------
2. MARKET VALUE OF LAND AND BUILDINGS MINUS MORTGAGES AND LIENS (e.g., second |  $              |  $              |
homes and non-income-producing property.  Do not count your primary home.)    |                 |                 |                

------------------------------------------------------------------------------------------------------------------------------------
3. VALUE OF OTHER PROPERTY OR ASSETS (e.g., art, rare coins, collectibles)    |  $              |  $              |
MINUS THE AMOUNT YOU OWE ON THESE ITEMS.  INCLUDE VALUE OF FARM, RANCH, OR    |                 |                 |
BUSINESS ASSETS.  Exclude household effects and family vehicles.              |                 |                 |                

------------------------------------------------------------------------------------------------------------------------------------

                                                 SECTION XI - CONSENT TO COPAYMENTS                                                

------------------------------------------------------------------------------------------------------------------------------------
If you are a 0% service-connected veteran and do not receive VA monetary benefits or a nonservice-connected veteran (and you are
not an Ex-POW, Purple Heart Recipient, WWI veteran or VA pensioner) and your household income (or combined income and net worth)
exceeds the established threshold, this application will be considered for enrollment, but only if you agree to pay VA copayments
for treatment of your nonservice-connected conditions.  If you are such a veteran, by signing this application you are agreeing
to pay the applicable VA copayment as required by law.
                                                                                                                                   

------------------------------------------------------------------------------------------------------------------------------------

                                                SECTION XII - ASSIGNMENT OF BENEFITS                                               

------------------------------------------------------------------------------------------------------------------------------------
I understand that pursuant to 38 U.S.C. section 1729, VA is authorized to recover or collect from my health plan (HP) for the
reasonable charges of nonservice-connected VA medical care or services furnished or provided to me.  I hereby authorize payment
directly to VA from any HP under which I am covered (including coverage provided under my spouse's HP) that is responsible for
payment of the charges for my medical care, including benefits otherwise payable to me or my spouse.
                                                                                                                                   

------------------------------------------------------------------------------------------------------------------------------------

      ALL APPLICANTS MUST SIGN AND DATE THIS FORM.  REFER TO INSTRUCTIONS WHICH DEFINE WHO CAN SIGN ON BEHALF OF THE VETERAN.
                                                                                                                                   

------------------------------------------------------------------------------------------------------------------------------------
SIGNATURE OF APPLICANT                                                                    | DATE
                                                                                          |
                                                                                          |                                        

------------------------------------------------------------------------------------------------------------------------------------
====================================================================================================================================
VA FORM 10-10EZ FEB 2005                PRINTED: Apr 01, 2013@15:12:13          Clerk: RA/                              PAGE 4


Select PATIENT NAME: 

Select ADT Outputs Menu Option: ADT Third Party Output Menu

Select ADT Third Party Output Menu Option: Patient Review Document
Select PATIENT NAME: 323554567  TWENTYFOUR,PATIENT X        3-2-48    323554567 
    YES     SC VETERAN      
No admissions on file, will check scheduled admissions

No scheduled admissions on file

Select ADT Third Party Output Menu Option: Review Document by Admission Range
START WITH DATE/TIME: FIRST// 
DEVICE:   TELNET




          *** NO RECORDS TO PRINT ***

Select ADT Third Party Output Menu Option: Veteran Patient Insurance Information

nformation
Sort by Discharge or Admission: D// DISCHARGE
START DATE: t  (APR 01, 2013)
  END DATE: t+10  (APR 11, 2013)

DEVICE: HOME//   TELNET


Select ADT Third Party Output Menu Option: 

Select ADT Outputs Menu Option: 

Select ADT Manager Menu Option: ADT Outputs Menu

Select ADT Outputs Menu Option: Bed Availability

(A)bbreviated or (E)xpanded Bed Availability Listing?  A//ABBREVIATED

Select WARD LOCATION NAME: TESTWARD1    
Do you want to display room-bed descriptions? No// yes  (Yes)

TESTWARD1:  
   1-A   (bed1)                         1-B   (bed2)
   2-A   (bed3)                         2-B   (bed4)

Select WARD LOCATION NAME: 


Select ADT Outputs Menu Option: Disposition Outputs Menu

Select Disposition Outputs Menu Option: Log of Dispositions
In process(I) or All(A): I// ALL

Note: This report requires a column width of 132.

START WITH LOG IN DATE/TIME: FIRST// 
DEVICE: HOME  TELNET
DISPOSITION TOTAL LOG                          APR  1,2013  15:12    PAGE 1
LOG-IN               LOG-OUT              PROCESS    DISPOSITION
                                                                         PT ID
                                                                                
        NAME
    REASON FOR LATE
    DISPOSITION
--------------------------------------------------------------------------------





          *** NO RECORDS TO PRINT ***

Select Disposition Outputs Menu Option: Disposition Time Processing Statistics

NO REGISTRATIONS ON FILE TO START WITH!!


Select Disposition Outputs Menu Option: 

Select ADT Outputs Menu Option: Enrollment Reports

Select Enrollment Reports Option: Enrolled Veterans Report
*** This report requires a 132 column printer. ******
DEVICE: HOME// HOME  TELNET
[1;1H[1;1H[J[2J[H
                            Enrolled Veterans Report
                                  Apr 01, 2013



CURRENTLY ENROLLED VETERANS AND VETERANS WITH PENDING APPLICATIONS

                                                           Enrolled        Not E
nrolled                                                                         
                 In Process

    =====================================
    Total:                              0                                       
               


    ==============================================================
    Total:                                                       0

Select Enrollment Reports Option: Select Enrollment Reports Option:Pending Applications for Enrollment
Enter Beginning Date:  t-100
Enter Ending Date:  Apr 01, 2013// 
Do you want the report for ALL facilities? YES// YES
*** This report requires a 132 column printer. ******
DEVICE: HOME// HOME  TELNET
[1;1H[1;1H[J[2J[H
Pending Applications For Enrollment - Enrollment Category is "In Process"
Date Range: Dec 22, 2012 to Apr 01, 2013           Run Date: Apr 01, 2013

AppDt            Name                                           PatientID       
 DOB
--------------------------------------------------------------------------------
----------------------------------------------------














Enter RETURN to continue or '^' to exit: 

Select Enrollment Reports Option: Enrollees by Status,Priority,Preferred Facilit
y
Do you want to include all Preferred Facilities? NO// YES
Do you want a list of selected patients? NO// no  NO
*** This report requires a 132 column printer. ******
DEVICE: HOME// HOME  TELNET
[1;1H[1;1H[J[2J[H
Enrollments by Status, Priority, and Preferred Facility                         
                    Page 1
  <<< SUMMARY STATISTICS >>>                                                    
                    Run Date: Apr 01, 2013

--------------------------------------------------------------------------------
----------------------------------------------------



 TOTAL FOR ALL SELECTED FACILITIES:          0









Enter RETURN to continue or '^' to exit: 

Select Enrollment Reports Option: Upcoming Appointments without Enrollment
Enter beginning date for future appointments for.:  Apr 02, 2013// 
Enter ending date:  Apr 02, 2013// 

     Select one of the following:

          A         All
          C         by Clinic

How do you want to select the clinics to appear in the report? : ALL// ALL  All
For patients with multiple appointments, should only the first be listed? NO// N
O
*** This report requires a 132 column printer. ******
DEVICE: HOME// HOME  TELNET
	 .S SDREF=$Q(@SDREF,SDDIR)
	                   ^-----
		At column 20, line 161, source module /home/softhat/VistA-Instance/r/SDAMA307.m
%GTM-E-RPARENMISSING, Right parenthesis expected
[1;1H[1;1H[J[2J[H
Appointments for Veterans with no Enrollment Application              Date Range
: Apr 02, 2013 to Apr 02, 2013                                                  
                                        Page 1
                                                                       Run Date:
 Apr 01, 2013

Name                                   PatientID         DOB          Appt Dt/Tm
          EnrollStatus                                                          
                                         Enroll Cat
--------------------------------------------------------------------------------
----------------------------------------------------








Enter RETURN to continue or '^' to exit: 

Select Enrollment Reports Option: EGT Impact Report
Select Actual or Preliminary: A
Select Detail or Summary: Summary
Report Begin Date: t-100  (DEC 22, 2012)
Report End Date: t+100  (JUL 10, 2013)
DEVICE: HOME// HOME  TELNET
[1;1H[1;1H[J[2J[H
                        EGT Actual Summary Impact Report
         Date Range of Enrollment End Date: Dec 22, 2012 - Jul 10, 2013
                   Date/Time Report Run: APR 1,2013 @ 15:12
 EGT Setting: 8d EGT Type: ENROLLMENT DECISION EGT Effective Date: Jun 15, 2009
                    Date/Time Last EGT Setting: Jun 10, 2009

IMPORTANT NOTE:  Actual report is based on a comparison of the EGT Setting and t
he Enrollment Category as provided by HEC.

ENROLLMENT PRIORITY    TOTAL (UNIQUE SSN)  # INPATIENT   # OUTPATIENT

TOTAL PATIENTS (UNIQUE SSNS) FOR THIS FACILITY:     0

Select Enrollment Reports Option: Non-Treating Preferred Facility Clean Up[15;1H[1;1H[J[2J[H

         NON TREATING PREFERRED FACILITY CLEAN UP REPORT
*****************************************************************

This process will find all patients that have a non-treating
Preferred Facility on file.  All identified patients will need
to have their Preferred Facility changed to a valid treating
facility.

The clean up process will perform the following steps in order:
     1) Compile the patient data.  (This step looks at 
        every patient in the PATIENT (#2) file.)  A summary
        MailMan message will be sent to the user when the
        compile is complete.
     2) The user will need to return to this option to print
        the detail report within 30 days to avoid recompiling.
        NOTE: The system will purge the compiled data after 30
        days!

All compiled data will be stored in the ^XTMP("DG53355A") global.

Do you want to continue? NO// Yes  YES

Requested Start Time: NOW//  (APR 01, 2013@15:12:19)

TaskMan Task: 1084

Select Enrollment Reports Option: 

Select ADT Outputs Menu Option: 