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Forms

Total Forms and Personal Health Materials

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

Forms and Personal Health Materials

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: Form
Last updated: May 9, 2024

Health Care Proxy

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Last updated: July 29, 2024

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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Last updated: January 3, 2022

Authorization for Release of Health Information Form (DOH 5032)

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Last updated: September 26, 2022

Health Information Exchange Fact Sheet and Form

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Last updated: August 15, 2023
Your Rights and Responsibilities

Making Decisions About Your Health Care

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Last updated: May 24, 2023

Patient Self-Determination Policies

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Last updated: June 2, 2023

Planning in Advance for Your Medical Treatment

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Last updated: June 1, 2023

Member Rights and Responsibilities upon Disenrollment

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Last updated: June 7, 2023

Multi-language Interpreter Services

Last updated: September 27, 2023
Prior Authorization Request Forms

Request for Medicare Prescription Drug Coverage Determination –
PDF Form

Download PDF: Determination Form
Last updated: March 31, 2023

Request for Medicare Prescription Drug Coverage Redetermination

Download PDF: Redetermination Form
Last updated: May 9, 2024

New York State Medicaid Prior Authorization Request Form for Prescriptions

Last updated: March 31, 2023

Medicare Prior Authorization Requirements

Last updated: May 22, 2024

Pre-Authorization Request Form for VNS Health Managed Long Term Care Plans

Last updated: May 9, 2024