Health Plans Documents

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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.

Member Forms
EasyCare Plus EasyCare 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
CDPAS Recertification – Physician Order Form

Total Members can have their home care service provided by a consumer directed personal care assistant through Consumer Directed Personal Assistance Services (CDPAS). The physician order form is required during the initial assessment and every 6 months during CDPAS recertification.

Download PDF:
Physician Order Form
Total EasyCare Plus EasyCare
Health Information Exchange Fact Sheet and Form
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Prior Authorization Request Forms
EasyCare Total EasyCare Plus
Medicare Prior Authorization Requirements
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Medicare Prior Authorization Requirements
Total EasyCare Plus EasyCare
New York State Medicaid Prior Authorization Request Form for Prescriptions
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NYS Medicaid Prior Authorization Request Form
EasyCare EasyCare Plus Total
Opioid Prior Authorization Request Form
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Opioid Prior Authorization Request Form
Total
Pre-Authorization Request Form for VNS Health Managed Long Term Care Plans
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Pre-Authorization Request Form
Total EasyCare Plus EasyCare
Request for Medicare Prescription Drug Coverage Determination – Online Form
Total EasyCare Plus EasyCare
Request for Medicare Prescription Drug Coverage Determination – PDF Form
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Determination Form