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July 2, 2024 21:06
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{ | |
"personalIdentification": { | |
"ssn": "3018", | |
"fileNumber": "3018", | |
"fsrReason": "Waiver" | |
}, | |
"personalData": { | |
"veteranFullName": { | |
"first": "Travis", | |
"middle": "D", | |
"last": "Jones" | |
}, | |
"address": { | |
"addresslineOne": "1200 Park Ave", | |
"addresslineTwo": "c/o Pixar", | |
"addresslineThree": "", | |
"city": "Emeryville", | |
"stateOrProvince": "CA", | |
"zipOrPostalCode": "94608", | |
"countryName": "US" | |
}, | |
"telephoneNumber": "(510) 922-4444", | |
"dateOfBirth": "09/06/1950", | |
"married": false, | |
"spouseFullName": { | |
"first": "", | |
"middle": "", | |
"last": "" | |
}, | |
"agesOfOtherDependents": [], | |
"employmentHistory": [ | |
{ | |
"veteranOrSpouse": "VETERAN", | |
"occupationName": "Full time", | |
"from": "01/2018", | |
"to": "", | |
"present": true, | |
"employerName": "Testing", | |
"employerAddress": { | |
"addresslineOne": "", | |
"addresslineTwo": "", | |
"addresslineThree": "", | |
"city": "", | |
"stateOrProvince": "", | |
"zipOrPostalCode": "", | |
"countryName": "" | |
} | |
} | |
] | |
}, | |
"income": [ | |
{ | |
"veteranOrSpouse": "VETERAN", | |
"monthlyGrossSalary": "5366.66", | |
"deductions": { | |
"taxes": "620.69", | |
"retirement": "0.00", | |
"socialSecurity": "0.00", | |
"otherDeductions": { | |
"name": "", | |
"amount": "0.00" | |
} | |
}, | |
"totalDeductions": "620.69", | |
"netTakeHomePay": "4745.97", | |
"otherIncome": { | |
"name": "", | |
"amount": "0.00" | |
}, | |
"totalMonthlyNetIncome": "4745.97" | |
}, | |
{ | |
"veteranOrSpouse": "SPOUSE", | |
"monthlyGrossSalary": "0.00", | |
"deductions": { | |
"taxes": "0.00", | |
"retirement": "0.00", | |
"socialSecurity": "0.00", | |
"otherDeductions": { | |
"name": "", | |
"amount": "0.00" | |
} | |
}, | |
"totalDeductions": "0.00", | |
"netTakeHomePay": "0.00", | |
"otherIncome": { | |
"name": "", | |
"amount": "0.00" | |
}, | |
"totalMonthlyNetIncome": "0.00" | |
} | |
], | |
"expenses": { | |
"rentOrMortgage": "3000.00", | |
"food": "0.00", | |
"utilities": "0.00", | |
"otherLivingExpenses": { | |
"name": "", | |
"amount": "0.00" | |
}, | |
"expensesInstallmentContractsAndOtherDebts": "0.00", | |
"totalMonthlyExpenses": "3000.00" | |
}, | |
"discretionaryIncome": { | |
"netMonthlyIncomeLessExpenses": "1745.97", | |
"amountCanBePaidTowardDebt": "0.00" | |
}, | |
"assets": { | |
"cashInBank": "100.00", | |
"cashOnHand": "100.00", | |
"usSavingsBonds": "0.00", | |
"stocksAndOtherBonds": "0.00", | |
"realEstateOwned": "0.00", | |
"totalAssets": "200.00" | |
}, | |
"installmentContractsAndOtherDebts": [], | |
"totalOfInstallmentContractsAndOtherDebts": { | |
"originalAmount": "0.00", | |
"unpaidBalance": "0.00", | |
"amountDueMonthly": "0.00", | |
"amountPastDue": "0.00" | |
}, | |
"additionalData": { | |
"bankruptcy": { | |
"hasBeenAdjudicatedBankrupt": false | |
}, | |
"additionalComments": "12" | |
}, | |
"applicantCertifications": { | |
"veteranSignature": "Travis D Jones", | |
"veteranDateSigned": "07/02/2024" | |
}, | |
"selectedDebtsAndCopays": [ | |
{ | |
"resolutionWaiverCheck": true, | |
"resolutionOption": "waiver", | |
"id": "f4385298-08a6-42f8-a86f-50e97033fb85", | |
"pSSeqNum": "506.00", | |
"pSTotSeqNum": "588.00", | |
"pSFacilityNum": "534", | |
"pSFacPhoneNum": null, | |
"pSTotStatement": "27.00", | |
"pSStatementVal": "0000018255H", | |
"pSStatementDate": "11152019", | |
"pSStatementDateOutput": "11/15/2019", | |
"pSProcessDate": "11112019", | |
"pSProcessDateOutput": "11/11/2019", | |
"pHPatientLstNme": "JONES", | |
"pHPatientFstNme": "TRAVIS", | |
"pHPatientMidNme": "D", | |
"pHAddress1": "1885 SHORE DR S APT 327", | |
"pHAddress2": null, | |
"pHAddress3": null, | |
"pHCity": "SAVANNAH", | |
"pHState": "FL", | |
"pHZipCde": "314104413", | |
"pHZipCdeOutput": "31410-4413", | |
"pHCtryNme": null, | |
"pHAmtDue": "15.00", | |
"pHAmtDueOutput": "15.00 ", | |
"pHPrevBal": "135.00", | |
"pHPrevBalOutput": "135.00 ", | |
"pHTotCharges": "15.00", | |
"pHTotChargesOutput": "15.00 ", | |
"pHTotCredits": "-135.00", | |
"pHTotCreditsOutput": "135.00- ", | |
"pHNewBalance": "15.00", | |
"pHNewBalanceOutput": "15.00 ", | |
"pHSpecialNotes": "To pay your statement online, go to www.pay.gov or call 1-888-827-4817.", | |
"pHroParaCdes": "304050556065708085", | |
"pHNumOfLines": "10.00", | |
"pHDfnNumber": "346310.00", | |
"pHCernerStatementNumber": "1005154223.00", | |
"pHCernerPatientId": "1005154223", | |
"pHCernerAccountNumber": "1005154223", | |
"pHIcnNumber": "1012845638V677813", | |
"pHAccountNumber": "0.00", | |
"pHLargeFontIndcator": "0.00", | |
"details": [ | |
{ | |
"pDDatePosted": "10072019", | |
"pDDatePostedOutput": "10/07/2019", | |
"pDTransDesc": "OUTPATIENT CARE(NSC)", | |
"pDTransDescOutput": "OUTPATIENT CARE", | |
"pDTransAmt": "-15.00", | |
"pDTransAmtOutput": "15.00- ", | |
"pDRefNo": "534-K90HEWN" | |
}, | |
{ | |
"pDDatePosted": "10072019", | |
"pDDatePostedOutput": "10/07/2019", | |
"pDTransDesc": "OUTPATIENT CARE(NSC)", | |
"pDTransDescOutput": "OUTPATIENT CARE", | |
"pDTransAmt": "-15.00", | |
"pDTransAmtOutput": "15.00- ", | |
"pDRefNo": "534-K90HEWN" | |
}, | |
{ | |
"pDDatePosted": "10072019", | |
"pDDatePostedOutput": "10/07/2019", | |
"pDTransDesc": "OUTPATIENT CARE(NSC)", | |
"pDTransDescOutput": "OUTPATIENT CARE", | |
"pDTransAmt": "-15.00", | |
"pDTransAmtOutput": "15.00- ", | |
"pDRefNo": "534-K90HEWN" | |
}, | |
{ | |
"pDDatePosted": "10072019", | |
"pDDatePostedOutput": "10/07/2019", | |
"pDTransDesc": "OUTPATIENT CARE(NSC)", | |
"pDTransDescOutput": "OUTPATIENT CARE", | |
"pDTransAmt": "-15.00", | |
"pDTransAmtOutput": "15.00- ", | |
"pDRefNo": "534-K90HEWN" | |
}, | |
{ | |
"pDDatePosted": "10072019", | |
"pDDatePostedOutput": "10/07/2019", | |
"pDTransDesc": "OUTPATIENT CARE(NSC)", | |
"pDTransDescOutput": "OUTPATIENT CARE", | |
"pDTransAmt": "-15.00", | |
"pDTransAmtOutput": "15.00- ", | |
"pDRefNo": "534-K90HEWN" | |
}, | |
{ | |
"pDDatePosted": "10072019", | |
"pDDatePostedOutput": "10/07/2019", | |
"pDTransDesc": "OUTPATIENT CARE(NSC)", | |
"pDTransDescOutput": "OUTPATIENT CARE", | |
"pDTransAmt": "-15.00", | |
"pDTransAmtOutput": "15.00- ", | |
"pDRefNo": "534-K90HEWN" | |
}, | |
{ | |
"pDDatePosted": "10072019", | |
"pDDatePostedOutput": "10/07/2019", | |
"pDTransDesc": "OUTPATIENT CARE(NSC)", | |
"pDTransDescOutput": "OUTPATIENT CARE", | |
"pDTransAmt": "-15.00", | |
"pDTransAmtOutput": "15.00- ", | |
"pDRefNo": "534-K90HEWN" | |
}, | |
{ | |
"pDDatePosted": "10072019", | |
"pDDatePostedOutput": "10/07/2019", | |
"pDTransDesc": "OUTPATIENT CARE(NSC)", | |
"pDTransDescOutput": "OUTPATIENT CARE", | |
"pDTransAmt": "-15.00", | |
"pDTransAmtOutput": "15.00- ", | |
"pDRefNo": "534-K90HEWN" | |
}, | |
{ | |
"pDDatePosted": "10072019", | |
"pDDatePostedOutput": "10/07/2019", | |
"pDTransDesc": "OUTPATIENT CARE(NSC)", | |
"pDTransDescOutput": "OUTPATIENT CARE", | |
"pDTransAmt": "-15.00", | |
"pDTransAmtOutput": "15.00- ", | |
"pDRefNo": "534-K90HEWN" | |
}, | |
{ | |
"pDDatePosted": "10152019", | |
"pDDatePostedOutput": "10/15/2019", | |
"pDTransDesc": "OUTPATIENT CARE(NSC) VISIT DATE: 09/07/2018", | |
"pDTransDescOutput": "OUTPATIENT CARE VISIT DATE: 09/07/2018", | |
"pDTransAmt": "15.00", | |
"pDTransAmtOutput": "15.00 ", | |
"pDRefNo": "534-K009FK8" | |
} | |
], | |
"station": { | |
"facilitYNum": "534", | |
"visNNum": "07", | |
"facilitYDesc": "RALPH H. JOHNSON VA MEDICAL CENTER (534)", | |
"cyclENum": "012", | |
"remiTToFlag": "L", | |
"maiLInsertFlag": "0", | |
"staTAddress1": "ACCOUNTS RECEIVABLE (04AR)", | |
"staTAddress2": "109 BEE ST", | |
"staTAddress3": null, | |
"city": "Charleston", | |
"state": "SC", | |
"ziPCde": "294015703", | |
"ziPCdeOutput": "29401-5703", | |
"baRCde": "*294015703090*", | |
"teLNumFlag": "P", | |
"teLNum": "1-866-258-2772", | |
"teLNum2": null, | |
"contacTInfo": null, | |
"dM2TelNum": null, | |
"contacTInfo2": null, | |
"toPTelNum": null, | |
"lbXFedexAddress1": null, | |
"lbXFedexAddress2": null, | |
"lbXFedexAddress3": null, | |
"lbXFedexCity": null, | |
"lbXFedexState": null, | |
"lbXFedexZipCde": null, | |
"lbXFedexBarCde": null, | |
"lbXFedexContact": null, | |
"lbXFedexContactTelNum": null, | |
"facilityName": "Ralph H. Johnson Department of Veterans Affairs Medical Center" | |
}, | |
"debtType": "COPAY", | |
"resolutionComment": "" | |
} | |
], | |
"streamlined": { | |
"value": false, | |
"type": "none" | |
} | |
} |
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