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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Form
Last updated: May 9, 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 StreetNew York, NY 10017
Authorization for Release of Health Information Form (DOH 5032)
Health Information Exchange Fact Sheet and Form
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
Last updated: September 27, 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: May 9, 2024
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: May 22, 2024
Pre-Authorization Request Form for VNS Health Managed Long Term Care Plans
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Pre-Authorization Request Form
Last updated: March 18, 2025