VNS Health Health Plans Logo

Forms

EasyCare Plus Forms and Personal Health Materials

If you have questions or want a printed copy of any of the VNSNY CHOICE EasyCare Plus (HMO D-SNP) materials on this page, please call us at 1-888-783-1444, 7 days a week, 8 am – 8 pm. TTY users should call 711.

Forms and Personal Health Materials

Health Care Proxy

Download PDF: English Spanish Chinese
Last updated: 11/08/2021

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: VNSNY CHOICE EasyCare Plus 220 East 42nd Street, 3rd floor, New York, NY 10017

Download PDF: English Spanish Chinese
Last updated: 01/03/2022

Authorization for Release of Health Information Form (DOH 5032)

Download PDF: English Spanish Chinese
Last updated: 09/26/2022

Health Information Exchange Fact Sheet

Download PDF: English Spanish Chinese
Last updated: 11/08/2021

Authorization for Access to Patient/Member Information Through a Health Information Exchange Organization

Download PDF: English Spanish Chinese
Last updated: 09/26/2022
Your Rights and Responsibilities

Making Decisions About Your Health Care

Download PDF: English Spanish Chinese
Last updated: 07/29/2020

Patient Self-Determination Policies

Download PDF: English Spanish Chinese
Last updated: 07/29/2020

Planning in Advance for Your Medical Treatment

Download PDF: English Spanish Chinese
Last updated: 07/29/2020

Member Rights and Responsibilities Upon Disenrollment

Download PDF: English
Last updated: 03/21/2022

Multi-language Interpreter Services

Last updated: 10/06/2022