Member Forms

Below you will find links to various forms and other documents that members of VNSNY CHOICE Total may sometimes have a need for. 

Of course, you can also call Member Services if you need additional information or support:

1-866-783-1444
(TTY users call 711)
Monday – Friday, 8 am - 8 pm

MLTC Forms
 
Authorization for Release of Health Information Pursuant to HIPAA (EnglishSpanishChinese, Korean, and Russian)
 
Health Care Proxy (EnglishSpanishChineseKorean, and Russian)
 
MA Forms
 
Release Health Info Forms (English and Spanish
Request for Medicare Prescription Drug Coverage Determintation Form (English)
Request for Medicare Prescription Drug Coverage Redetermination Form (English
Appointment of Representitive Form (EnglishSpanish)
 
Additional Documents
 
Making Decisions About Your Medical Care (EnglishSpanishChineseKorean, and Russian)
 
Patient Self-Determination Policies (EnglishSpanish, ChineseKorean, and Russian)
 
Planning in Advance for Your Medical Treatment (EnglishSpanishChineseKorean, and Russian)
 
MLTC Bill of Rights (English, SpanishChineseKorean, and Russian)
 
Notice of Privacy Practices (EnglishSpanishChineseKorean, and Russian)
 
This is a Medicare-related page; some of the links will take you to non-Medicare information or to a different website.

VNSNY CHOICE Medicare Total is an HMO SNP plan with a Medicare contract. This plan is also a Medicaid Advantage Plus plan, with a contract with the New York State Department of Health. Enrollment in VNSNY CHOICE Medicare depends on contract renewal.

Last updated 2/15/2017

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