AFL Update Form | Vaya Health

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?*
- Add a new home
- Change an address
- Member change
- Close an AFL
- Change in provider
Required 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 ID*
Member Name*
First Last
Funding Source*
Provider Name*
Provider Address*
QP or Primary Contact Person*
QP or Primary Contract Phone Number and Extension*
QP or Primary Contact Email Address*
Effective Date of Change*
Actual or Estimated
Please complete if you checked new, member change or provider change.
AFL Primary Caregiver First and Last Name (s):
AFL Home Name
AFL Address
Street Address Address Line 2 City State ZIP Code
County
Please complete if changing an address
AFL Primary Caregiver / AFL Home Name
Old Address
Street Address City State ZIP Code
County
New Address to be reviewed
Street Address City State ZIP Code
County
Please complete if you checked AFL closing.
AFL Primary Caregiver First and Last Name (s):
AFL Home Name (if different than above):
Street Address City State ZIP Code
County
Comments
Submit 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.

Required for all submissions.

Please complete if you checked new, member change or provider change.

Please complete if changing an address

Please complete if you checked AFL closing.

Comments