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Forms

EasyCare Plus Forms and Personal Health Materials

Looking for more in-depth information about your VNS Health EasyCare Plus (HMO D-SNP) plan? You’ll find it here, along with forms and other tools and materials.

If you have questions about any of the materials listed here, call us at 1-866-414-6715 (TTY: 711), 7 days a week, 8 am–8 pm (TTY users, call: 711).

Note that this plan’s name will change to VNS Health EasyCare Plus on January 1, 2023. 

Forms and Personal Health Materials

Health Care Proxy

Download PDF: English Spanish Chinese
Last updated: August 15, 2023

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 – EasyCare Plus
220 East 42nd Street, New York, NY 10017

Download PDF: English Spanish Chinese
Last updated: January 3, 2022

Authorization for Release of Health Information Form (DOH 5032)

Download PDF: English Spanish Chinese
Last updated: September 26, 2022

Health Information Exchange Fact Sheet and Form

Download PDF: English Spanish Chinese
Last updated: August 15, 2023
Your Rights and Responsibilities

Making Decisions About Your Health Care

Download PDF: English Spanish Chinese
Last updated: May 24, 2023

Patient Self-Determination Policies

Download PDF: English Spanish Chinese
Last updated: June 2, 2023

Planning in Advance for Your Medical Treatment

Download PDF: English Spanish Chinese
Last updated: June 1, 2023

Member Rights and Responsibilities Upon Disenrollment

Download PDF: English Spanish Chinese
Last updated: June 7, 2023

Multi-language Interpreter Services

Last updated: October 1, 2023