VNS Health Health Plans Logo

Forms

Total Forms and Personal Health Materials

Looking for more in-depth information about your VNS Health Total (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 should call 711.

Forms and Personal Health Materials

CDPAS Recertification – Physician Order Form

VNS Health 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 six months during CDPAS recertification.
Download PDF: Form
Last updated: 03/18/2021

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:
VNS Health
Health Plans – Total
220 East 42nd Street, 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