

Memo1
BEGIN SL list:
THE VETERAN WAS ENROLLED INTO THE HCHV CONTRACT PROGRAM AT BRIDGE HOUSE ON {FLD:`00001DATE (REQ)}

1.  STAFF MEMBER COMPLETING THIS REPORT: {FLD:`00002WORD PROCESSING SHORT REQUIRED}
    ROLE: {FLD:`00003502 HOMELESS VET STAFF ROLE}

1A. VA STAFF MEMBER REVIEWING THIS REPORT: {FLD:`00004WORD PROCESSING SHORT REQUIRED}
    ROLE:{FLD:`00005502 HOMELESS VET VA STAFF ROLE}

2.  VA FACILITY CODE: {FLD:`00006WORD PROCESSING SHORT REQUIRED}

I. VETERAN INFORMATION

3. VETERAN'S NAME: |PATIENT NAME|

4. SOCIAL SECURITY NUMBER: |PATIENT SSN|

5. VETERAN'S DATE OF BIRTH: 

II. RESIDENTIAL TREATMENT STAY

6. WHAT IS THE SOURCE OF PAYMENT FOR THE DAYS OF RESIDENTIAL TREATMENT COVERED
   BY THIS REPORT?{FLD:`00007502 HOMELESS VET SOURCE PYMT}{FLD:`00008WORD PROCESSING SHORT}

7. NAME OF RESIDENTIAL PROVIDER: {FLD:`00009WORD PROCESSING SHORT REQUIRED}

8. PERIOD COVERED BY THIS REPORT:	
   BEGINNING: 
   ENDING: 

9. NUMBER OF DAYS: {FLD:`00010WORD PROCESSING SHORT REQUIRED}

10. COST OF TREATMENT UNDER THIS PROVIDER (ROUND TO NEAREST DOLLAR): {FLD:`00011WORD PROCESSING SHORT REQUIRED}

III. STATUS AT END OF TREATMENT

11. THE VETERAN ENDED RESIDENTIAL TREATMENT BECAUSE:{FLD:`00012502 HOMELESS VET END TX REASON}{FLD:`00013WORD PROCESSING SHORT}

12. IF THE VETERAN ENDED RESIDENTIAL TREATMENT BECAUSE OF A RULE VIOLATION, 
    WHAT WAS THE MOST IMPORTANT REASON? {FLD:`00014502 HOMELESS VET VIOLATION REASON}{FLD:`00015WORD PROCESSING SHORT}

13. THE VETERAN'S LIVING SITUATION AT DISCHARGE IS: {FLD:`00016502 HOMELESS VET LIVING SITUATION}

14. WITH WHOM WILL THE VETERAN BE LIVING AT DISCHARGE?^@=00100;0;-1;;0^@@^
END SL list:
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