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.
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Form
Last updated: March 18, 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 – 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
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Multi-Language Insert (MLI)
Last updated: September 28, 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: November 15, 2020
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: August 12, 2022
Pre-Authorization Request Form for VNS Health Managed Long Term Care Plans
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Pre-Authorization Request Form
Last updated: September 14, 2020