Health Plans Documents

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Forms for EasyCare

Choose your plan to view or download forms you or your health care provider may need. You can also select specific document types to view or download the ones you need.

Forms
EasyCare EasyCare Plus Total
Appointment of Representative Form

You may appoint a relative, friend, attorney, or anyone else whom you trust to act on your behalf. A representative who is appointed by the court or who is active in accordance with state law may also file an appeal or grievance for you. To appoint a representative you must complete an Appointment of Representative form.

You can give us a copy of the form or letter or mail it to:
VNS Health
Health Plans – Care Team
220 East 42nd Street
New York, NY 10017

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Total EasyCare Plus EasyCare
Authorization for Release of Health Information Form (DOH 5032)
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Total EasyCare Plus EasyCare
Health Information Exchange Fact Sheet and Form
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Prior Authorization Request Forms
EasyCare EasyCare Plus Total
Medicare Prior Authorization Requirements
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Medicare Prior Authorization Requirements
EasyCare Total EasyCare Plus
New York State Medicaid Prior Authorization Request Form for Prescriptions
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NYS Medicaid Prior Authorization Request Form
Total EasyCare Plus EasyCare
Opioid Prior Authorization Request Form
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Opioid Prior Authorization Request Form
EasyCare Plus Total EasyCare
Request for Medicare Prescription Drug Coverage Determination – Online Form
EasyCare Plus EasyCare Total
Request for Medicare Prescription Drug Coverage Determination – PDF Form
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Determination Form
EasyCare EasyCare Plus Total
Request for Medicare Prescription Drug Coverage Redetermination
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Redetermination Form