Consistent with System of Care principles, the Universal Child and Adolescent Residential Application offers a comprehensive clinical review of a member's needs for purposes of admission to a residential provider contracted with Vaya Health. Please follow the instructions below:
1. This application, including all sections, must be completed in its entirety. Answer each question, indicating "N/A" if not applicable. Applications may be returned to referring party if deemed incomplete.
2.Do not enter "see attached" in sections requiring specific detail. If you have a document that provides greater detail than can be entered, reference the document name, date and page number at the end of your explanation. (e.g., Physical Assessment, 07.01.15, page 3). Submit any reference documentation along with this application.
3.The person completing this application is responsible for obtaining necessary releases/authorizations to disclose protected health information.
4.The Universal Application must be signed by the legally responsible person as defined at N.C.G.S. § 122C-3(20): "a parent, guardian, a person standing in loco parentis, or a legal custodian other than a parent who has been granted specific authority by law or in a custody order to consent for medical care, including psychiatric treatment."
Disclaimer: This form was created for the convenience of referring agencies/individuals to streamline discharge planning and eliminate time and redundancy associated with multiple agency-specific applications. Use of this form does not, and should not be construed to, guarantee authorization of residential or other treatment by Vaya. Moreover, responsibility for appropriate discharge from inpatient facilities remains with the discharging provider.