AFL Update Form A form for Vaya Health providers to update AFL information. ATTENTION: If Vaya Health has not approved your HCBS Self-Assessment for this site, do not complete this form. A site review will not be conducted until your agency has received Vaya approval of the HCBS Self-Assessment for this site.If the provider agency adds a new AFL site or if the member placed in an AFL home should change at any time, the provider must contact Vaya Health immediately to inform the Contract Performance Department of the change. What are you here to do today?*Member moving to a new or vacant unlicensed AFLExisting AFL and member moving to your agencyMember moving from one unlicensed AFL to another unlicensed AFLAFL and member moving to a new addressSite is no longer providing unlicensed AFL services to this memberAFL is no longer with this provider agencyRequired for all submissions.Required for submission* Per Clinical Coverage Policy No: 8-P, unlicensed supervised living homes (AFLs) may only serve one adult based on 10A NCAC 27 G.5601 (b) (1) (2). In accordance with the above regulation, provider attests that no other adult or child is receiving Innovations waiver services in the home. Member LME/MCO Record Number*Member Name* First Last Funding Source*Select OneInnovationsState FundedLong Term Community SupportB(3) Provider Agency Name*Provider Agency Address*QP or Primary Contact Person*QP or Primary Contract Phone Number and Extension*QP or Primary Contact Email Address* Effective Date of Change*This date must be after the date HCBS self-assessment meets full compliance.AFL Primary Caregiver First and Last Name (s):AFL Home NameNeeds to be the site name used when submitting the HCBS Self Assessment. AFL Address Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code AFL AddressIf you checked: Member moving to a new or vacant unlicensed AFL to another unlicensed AFL; or AFL provider and member are moving to a new address this should be the NEW address to be reviewed. Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code CountyPlease complete if changing an addressThe member is no longer living in this address. AFL Primary Caregiver / AFL Home NameOld Address Street Address City State AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code CountyCommentsSubmit any additional comments or questions below.QUESTIONS? Email all questions to afl.info@vayahealth.com. REMINDER: Any emails containing protected health information and/or member identifiers must be sent through SSL securely either via secure electronic mail, hand delivery, U.S. mail or courier.