Hope & Healing Hurricane Recovery Application 26-27

Applicant's Full Name (Applicant is the person receiving I/DD services)

Last NameFirst Name

Applicant's Date of Birth

Date

Applicant's Medicaid ID #

If you do not have Medicaid because you are state funded, please check box

Diagnosis of Applicant/Vaya Health Member

Applicant's Last Four #'s of Social Security

Applicant's Vaya Health Care Manager (not required)

Applicant's Address of Residence

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Applicant's Mailing Address (if different from Address of Residence)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Applicant's Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Applicant's County or Area of Residence

19 Counties and Eastern Band of Cherokees Indians

If the applicant is a minor, what is the full name of the parent?

Parent's Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Criteria for Participation (Check all that apply)

Type of Assistance Being Requested (Check all that apply)

Current Needs (Check all that apply)

Requested Amount of Assistance for Rent

$ Needed

Requested Amount of Assistance for Utilities

$ Needed

Sources of Documentation

Release of Information Authorization

Hope & Healing Hurricane Recovery Program (Funded by Vaya Health)
Participant Name: First Name Last Name
Date of Birth: Date

Purpose of This Authorization

I give permission for The Arc of Buncombe County’s Hope & Healing Program to share and receive information about me for the purpose of helping connect me to services and supports.

Who Can Share and Receive Information

This includes communication between:

The Arc of Buncombe County (Hope & Healing Program)
Vaya Health
Other social service agencies, healthcare providers, and public utilities, and property owners, and community organizations involved in my care or assistance

Information That May Be Shared

Only information needed to coordinate services, which may include:

Contact information
Basic health and support needs
Services I am receiving or requesting
Care coordination notes

Your Rights

I understand this is voluntary.
I can cancel (revoke) this permission at any time in writing.
Information shared may no longer be protected once sent to another agency.

Expiration

This authorization will expire 1 year from signature:

Signature

I have read and understand this form and give my permission as described above.
Signature:   Signature
Printed Name:   First Name   Last Name
Date:   Date
If signed by guardian/representative:
Relationship:   Signature
Printed Name:    First Name   Last Name

Hope & Healing Hurricane Recovery Application

CLIENT/APPLICANT'S INFORMATION

NEEDS ASSESSMENT

DOCUMENTATION CHECKLIST