Member Forms

Member Forms

Below you will find links to various forms and other documents that members of VNSNY CHOICE may sometimes have a need for.
 
Of course, you may call Member Services if you need additional information or support:
 
1-888-VNS-6555 
(1-888-866-6555)
(TTY for the hearing impaired: 711)
Monday - Friday, 9 am - 5 pm 
 
MLTC Forms
 
Authorization for Release of Health Information Pursuant to HIPAA (English, Spanish, Chinese, Korean, and Russian)
 
Health Care Proxy (English, Spanish, Chinese, Korean, and Russian)
 
Additional Documents:
 
Making Decisions About Your Medical Care (English, Spanish, Chinese, Korean, and Russian)
 
Patient Self-Determination Policies (English, Spanish, Chinese, Korean, and Russian)
 
Planning in Advance for Your Medical Treatment (EnglishSpanishChineseKorean, and Russian)
 
MLTC Bill of Rights (English, Spanish, Chinese, Korean, and Russian)
 
Notice of Privacy Practices (English, Spanish, Chinese, Korean, and Russian)
 

Find a Provider in Your Area

CHOICE MLTC members can continue seeing their current doctors and do not have to choose from the network. CHOICE uses a network of community providers to deliver many services our MLTC members need. This directory can help you find an MLTC network provider.