PROGRAM APPLICATION FOR FAIRVIEW HOUSING

Referring Facility or Agency

If you are not currently in a facility, please proceed to nextthe section.

Facility or Agency NameText field

Facility AddressText field

Person Making ReferralText field

Contact NumberText field

Fax NumberText field

Referring Person's email Text field

Date of DischargeDate

Personal Application Information

What program are you requesting service from?Dropdown

Client first nameClient middle nameClient last name

GenderRadio buttons

Client AddressClient AddressClient CityClient StateClient Zip

Client PhoneClient phone

Client BirthdateClient birthdate

SSNText field

Email AddressText field

Second Contact NumberText field

Primary Insurance Provider Text field

Do you have VA MedicaidCheckboxes

VA Medicaid ID Number Text field

Date Bed NeededDate

How did you hear about us? Text field

Current Housing Needs

What is the applicant's current housing plans if not accepted at one of our facilities? Text field

Is the applicant at high risk for homelessness? Checkboxes

Criminal History

Has the applicant been convicted or accused of any violent offenses?Checkboxes

If so, please describe.Text field

Has the applicant been convicted or accused of any sexual offense?Checkboxes

If so, please describe.Text field

Screening Information

Has the applicant been free of substances for the past 30 days (or will they have completed a detox by the time of the requested admission)? Checkboxes

Estimated date of when they will have completed 30 days of detox.Date

Has the applicant been diagnosed with a substance use disorder (SUD)? Checkboxes

If so, please include the diagnosis (Dx codes are acceptable)

Client diagnosis

Will the resident be receiving Medication Assisted Treatment Services and/or will that follow up be scheduled prior to their discharge from current facility? Checkboxes

Potential Follow up ProviderText field

Are there any medical issues that are currently not under control or are being addressed by a physician? For example, uncontrolled diabetes, high blood pressure, chronic kidney disease? Complete medical portion or submit a copy of medical records. Medical records will be required for anyone deemed to need medical clearance. Client health problems

Is the applicant in need of mental health services?Checkboxes

Please list primary symptomsText field

Any current suicidal thoughts?Checkboxes

Any history of suicidal attempts? Checkboxes

WhenText field

If yes, was there a hospitalization?Checkboxes

Records May Be Required From That Facility Name of HospitalText field

Summarize why the applicant wants to receive services at our facility. Paragraph

Mini Health Questionnaire

General: Please Check all that apply

Checkboxes

Comments:

Text field

Skin: Please check all that apply

Checkboxes

Comments:

Text field

Head: Please check all that apply

Checkboxes

Comments:

Text field

Ears: Please check all that apply

Hard of Hearing:

Checkboxes

Earache:

Checkboxes

Ringing In Ears:

Checkboxes

Comments:

Text field

Eyes: Check all that apply

Checkboxes

Date of Last eye Exam: Text field

Nose: Check all that apply

Checkboxes

Comments:

Text field

Throat: Check all that apply

Checkboxes

Date of Last Dental Exam: Text field

Comments:

Text field

Neck: Check all that apply

Checkboxes

Comments:

Text field

Breasts: Check all that apply

Checkboxes

Comments:

Text field

Musculoskeletal: Check all that apply

Checkboxes

Do you use any assistive devices:

Checkboxes

Comments:

Text field

Respiratory: Check all that apply

Do you have a cough?

Checkboxes

Do you have a C-Pap machine: Checkboxes

Comments:

Text field

Cardiovascular: Check all that apply

Checkboxes

Comments:

Text field

Gastrointestinal: Check all that apply

Checkboxes

Do you have an Ostomy? Checkboxes

If so, where is it placed? Text field

Can you manage the ostomy yourself? Checkboxes

Comments:

Text field

Urinary: Check all that apply

Checkboxes

Do you have a Urostomy? Checkboxes

If so, can you manage the urostomy yourself? Checkboxes

Comments:

Text field

Genital:

Checkboxes

Do you have any STDs? Checkboxes

If so, please list Text field

Comments:

Text field

Neurological: Check al that apply

Checkboxes

Comments:

Text field

Do you have a gambling disorder?Checkboxes

Do you have any food or medication allergies? Checkboxes

If so, please list Text field

Are you experiencing any Psychosis (Hallucinations/Auditory Hallucinations)?Checkboxes

If so, please explainText field

Are there any additional health concerns that you are experiencing that are not mentioned?Checkboxes

If so, please explainText field

I hereby affirm that the information in this document is correct and true to the best of my knowledge.

SignatureSignature

________________________________________________________

RELEASE OF INFORMATION

Option A: Completing and signing the Release of Information section of your application can help us verify your details more efficiently and speed up the review process. While this step is optional, we strongly encourage you to consider filling out and signing this portion to avoid potential delays and ensure a smoother application experience.

Authorization for Release/USE/Disclosure/Exchange of Protected Health Information from a Third Party Participant whose protected health information is being disclosed/exchanged:

Full Legal Name:Text field

Date of Birth:Text field

Record Number:Text field

I authorize Fairview Housing Management Corporation and its programs: 2513 Wesley St, Johnson City, TN 37601 (423) 929-8656 and its facilities: Bristol Lifestyle Recovery (261 North State Street, Bristo, VA 24201) and Mended Women Lifestyle Recovery (482 Bradley Street, Abingdon, VA, 24210) to DISCLOSE and EXCHANGE information with:

Bristol Pharmacy 2373 Lee Hwy Bristol, VA 24201 (276) 591-2520, CVS Pharmacy 3030 W State St, Bristol, TN 37620, (423) 764-7105, Walgreens Pharmacy, 2412 W State St. Bristol, TN, 37620 (423) 764-3261, Kroger Pharmacy 130 Stateline Ctr, Bristol, VA 24201 (276) 642-0032, Catalyst Health Solutions 926 W. Oakland Avenue Ste 206, Johnson City, TN 37604 (423) 282-3379 via both in person, phone, and fax.

You are encouraged to complete this form, but assistance is available at your request.

Description of Information requested for disclosure/exchange:

Psychiatric Information; Diagnostic Review; Lab results; Screenings; Substance Abuse Information; Psychological Evaluation; Discharge/Case Closure; Medical Information

Please note that any documentation in the treatment record that is protected by Federal Regulation 42 CFR part 2 OR other applicable laws may be disclosed. This includes information concerning HIV, Aids and HIV related illness, sexually transmitted diseases or other serious communicable illness which may be controlled by various laws and regulations. I consent to disclosure of such information with my signature/Date

The specified purpose or need for use/disclosure/exchange:

Coordination of Treatment and Medical Clearance

At the request of the participant or person representative?

Yes

*As the person signing this authorization at any time, except to the extent that action has been taken in the reliance upon it, by delivering the revocation in writing to the provider in possession of my health care records. There is a potential for any information disclosed/exchanged pursuant to this authorization to be subject to re-discloser by the recipient and therefore, no longer protected by the provision of the HIPPA Privacy Rule.

If the information is being disclosed/exchanged from records protected by the Federal Substance Abuse Confidentiality Rules ( 42CFR, Part 1) the Federal rules prohibit the recipient from making any further disclosure/exchange of the information, unless further disclosure is expressly permitted by my written authorization or as otherwise permitted by 42CFR part 2. A general authorzation for the disclosure/release of medical or other information is NOT sufficient for this purpose.

*Is this authorization limited to a single disclosure/exchange?

*this authorization will expire in

One Year

*This information may be disclosed/exchanged effective:

Immediately

*Does this authorization extend to information placed in my record after I sign this form?

Yes

*Is there any information that you do NOT want released?

DO NOT SIGN THIS FORM UNLESS ALL SECTIONS ARE COMPLETE AND YOU AGREE THAT IT IS ACCURATE

Participant Signature:Signature

Authorized Representative Signature:Signature

Parent or Guardian Signature:Signature

Staff signature indicates that a copy of this authorization was offered to the participant and that all information has been reviewed with the participant or representative.

Staff Signature:Signature

VOID:

By signing below, you ackowledge that you are requestion these permissions be voided.

Participant Signature Indication Void:Signature

Staff Signature Indicating Void:Signature