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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), weekdays, 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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Last updated: 03/18/2021

Health Care Proxy

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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 – Care Team
220 East 42nd Street
New York, NY 10017

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Last updated: 01/03/2022

Authorization for Release of Health Information Form (DOH 5032)

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Last updated: 09/26/2022

Health Information Exchange Fact Sheet

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Last updated: 05/24/2023

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

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Last updated: 09/26/2022
Your Rights and Responsibilities

Making Decisions About Your Health Care

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Last updated: 05/24/2023

Patient Self-Determination Policies

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Last updated: 07/29/2020

Planning in Advance for Your Medical Treatment

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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: 05/24/2023