Participant Forms

Below you will find links to various forms and other documents that participants of VNSNY CHOICE FIDA Complete (Medicare-Medicaid Plan) may sometimes have a need for.

Of course, you may call Participant Services if you need additional information or support:
 
1-866-783-1444
(TTY: 711)
7 days a week, 8 am - 8 pm
 
Release Health Info Forms  (EnglishSpanish)
 

Your Prescription Mail Order Form/Brochure (English)

Appointment of Representative Form (English and Spanish)
If you want a friend, relative, or other person to be your representative, you can either complete this “Appointment of Representative” form and give us a copy of the signed form or you can write and sign a letter indicating who you want to be your representative and give us a copy of the letter. You can give us a copy of the form or letter or mail it to VNSNY CHOICE FIDA Complete, 1250 Broadway, 11th floor, New York, NY 10001
 
Appointing Your Health Care Proxy 
(English, Spanish, Chinese, Korean, Russian, Haitian-Creole, Italian)
 
 
 
This is a FIDA-related page; some of the links will take you to non-FIDA information or to a different website. 
 
VNSNY CHOICE FIDA Complete is a managed care plan that contracts with both Medicare and the New York State Department of Health (Medicaid) to provide benefits of both programs to Participants through the Fully Integrated Duals Advantage (FIDA) Demonstration. 
 
You can get this information for free in other formats, such as Braille or audio CD. Call toll free 1-866-783-1444, TTY: 711, 8 am – 8 pm, 7 days a week. The call is free.
 
Enrollment in VNSNY CHOICE FIDA Complete depends on contract renewal.
 
Last updated 10/28/2016
 

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