AFL Update Form ATTENTION: 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 Network Performance Unit of this change. Attest to the below requirements*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 mental health, intellectual/developmental disability, and/or substance use services in the home. I attest no other adult or child is receiving mental health, intellectual/developmental disability, and/or substance use services in the home. Vaya Health has approved an HCBS self assessment for this site.* Yes No Regarding HCBS self assessments Providers of N.C. Innovations – Residential Supports, Day Supports and Supported Employment or CAP/DA/CAP CHOICE – Adult Day Health Services The HCBS Provider Self-Assessment must be completed in full on the N.C. Department of Health and Human Services website. Failure to complete the form and answer all questions could result in a delay of approval. If you have any questions, contact HCBS@vayahealth.com. Providers of Long-Term Community Support Services Please download the HCBS Form here, complete and submit to HCBS@vayahealth.com. Failure to complete the form and answer all questions could result in a delay of approval. For additional support, contact HCBS@vayahealth.com..' QUESTIONS? Email 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. What are you here to do today?* New or vacant unlicensed AFL (Member is new to AFL Services) Member and existing AFL moving to your agency (AFL & Member have changed providers) Member is remaining with your agency but moving to a different AFL address & Primary Caregiver Member and AFL moving to a new address (physical address of the AFL is changing) Site is no longer providing unlicensed AFL services to this member AFL is no longer with this provider agency (This AFL and member are now receiving AFL services through another agency) Why? The AFL is now licensed The member is still at this address, but the service has changed The member is deceased 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 Name Needs 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 County Please complete if changing an addressThe member is no longer living in this address. AFL Primary Caregiver / AFL Home Name Old 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 County CommentsSubmit 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. Δ