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:

(TTY users call 711)
7 days a week, 8 am – 8 pm

MLTC Forms
Authorization for Release of Health Information Pursuant to HIPAA (EnglishSpanishChinese, Korean, Russian)
Health Care Proxy (EnglishSpanishChineseKorean, Russian)
MA Forms
Authorization for Release of Health Information (EnglishSpanishChinese)
Request for Medicare Prescription Drug Coverage Determination Form (English)
Request for Medicare Prescription Drug Coverage Redetermination Form (English
Appointment of Representative Form (EnglishSpanish)
Opioid Prior Authorization Request Form (English)
Additional Documents
Making Decisions About Your Medical Care (EnglishSpanishChineseKoreanRussian)
Patient Self-Determination Policies (EnglishSpanish, ChineseKoreanRussian)
Planning in Advance for Your Medical Treatment (EnglishSpanishChineseKoreanRussian)
CHOICE MLTC Bill of Rights (English, SpanishChineseKoreanRussian)
VNSNY CHOICE Notice of Privacy Practices (EnglishSpanishChinese)
VNSNY CHOICE 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 Total depends on contract renewal. This information is not a complete description of benefits. Call 1-866-783-1444 (TTY: 711) for more information.  
This is a Medicare-related page; some of the links will take you to non-Medicare information or to a different website. 
Last updated 1/17/2019


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