Forms

Instructions

All forms are in Adobe .pdf format. Depending on the version of Adobe you have installed on your computer you may be able to fill-out the form electronically, print the information you filled-in, and save the information. Most versions of Adobe will allow you to save a blank form, fill-in the information and print the information, but not save the information filled-in.

Annual

(The forms below must be filled out & signed annually by consumers(if not conserved), or by conservators)

• Annual Consent-Rights-Surveys Packet – Complete-Rev
• Annual Physical – Physician’s Report – LIC602

Medical Authorization

• Available and Unavailable Immunization Records
• Consent for Medical Treatment – LIC627C
• DR Note – Injury Requiring Medical Care – Return to Program
• DR Note – Potentially Contagious Illness – Return to Program (Example)
• DR Note – Psychiatric Hospitalization – Return to Program
• Dr_Note_Illness_Example
• Dr_Note_Injury_Example
• Dr_Note_Psychiatric_Example
• Medication and Allergy Information Sheet
• Physical_Phycisians_Report
• Prescriptions – Physician’s Orders

Referral Packet

(Please fill out all of the forms below & obtain appropriate signatures, then return to Unyeway)

• Admission Agreement
• Admission Application
• Annual Physical – Physician’s Report – LIC 602
• Consent for Medical Treatment – LIC 627C
• Consent for Release of Emergency Medical Care
• Consent for Release of Information – Family
• Consent for Release of Information – Residential
• Consent for Release of Information – SDRC
• Consent for Release of Photo
• Consumer Employment Application
• Face Sheet Information
• Fact Sheet Information
• Grievance Procedure Acknowledgment
• Medication and Allergy Information Sheet
• ONLINE INTAKE PACKET – COMPLETE
• Personal Rights – LIC 613
• Prescriptions – Physician’s Orders
• PRN Authorization Letter
• Rights of People with Developmental Disabilities – DSP 304

Spanish Translation –Traducción al Español

(Please fill out all of the forms below & obtain appropriate signatures, then return to Unyeway)

• Consentimiento Para Tratamiento Medico De Emergencia – LIC627CSP
• Derechos Personales – LIC613SP
• Encuesta de Satisfacion – Padre y Proveedor

General (alphabetical)

• Admission Agreement 4-Rev
• Admission Agreement 4
• Admission Application-Rev
• Available and Unavailable Immunization Records
• Consent for Release of Emergency Medical Care-Rev
• Consent for Release of Information – Family Members-Rev
• Consent for Release of Information – Residential-Rev
• Consent for Release of Information – SDRC-Rev
• Consent for Release of Photograph
• Consent for Release of Photograph_1
• Consentimiento Para Tratamiento Medico De Emergencia – LIC627CSP
• Consumer Employment Application-Rev
• Derechos Personales – LIC613SP
• Encuesta de Satisfacion – Padre y Proveedor
• Face Sheet Information
• Fact Sheet Information
• Grievance Procedure Acknowledgment
• Online Intake Packet – Complete-Rev
• PRN Authorization Letter
• Personal Rights – LIC613
• Rights of Individuals with DD – DSP304
• Satisfaction Survey – Parents and Care Providers
• Personal_Rights
• Prn_Authorization_Letter
• Rights_of_Individuals_With_DD