EasyCare Plus Forms and Personal Health Materials
If you have questions or want a printed copy of any of the VNS Health EasyCare Plus (HMO D-SNP) materials on this page, please call us at 1-888-783-1444, weekdays, 8 am-8 pm. TTY users should call 711.
Forms and Personal Health Materials
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 HeathHealth Plans – Care Team 220 East 42nd StreetNew York, NY 10017
Authorization for Release of Health Information Form (DOH 5032)
Your Rights and Responsibilities
Making Decisions About Your Health Care
Patient Self-Determination Policies
Planning in Advance for Your Medical Treatment
Member Rights and Responsibilities Upon Disenrollment
Multi-language Interpreter Services
Last updated: September 27, 2023
Prior Authorization Request Forms
Request for Medicare Prescription Drug Coverage Determination – PDF Form
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Determination Form
Last updated: March 31, 2023
Request for Medicare Prescription Drug Coverage Redetermination
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Redetermination Form
Last updated: May 9, 2024
New York State Medicaid Prior Authorization Request Form for Prescriptions
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NYS Medicaid Prior Authorization Request Form
Last updated: March 31, 2023
Medicare Prior Authorization Requirements
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Medicare Prior Authorization Requirements
Last updated: May 22, 2024