Skip to main content

Forms for Providers and Patients

Here you can find forms to join our network, update your demographic information, get prior authorizations for a patient’s medications, and more. You can find credentialing forms by clicking on this link.

Required for All Current Providers

Provider Disclosure Certification

You are required to fill out and return this Provider Disclosure Certification form to VNSNY CHOICE. Please return it by December 31, 2021.

You can scan the completed document and email it as an attachment to:

Or you can print it out and mail it to:
220 East 42nd Street, Third Floor
New York, NY 10017
ATTN: Provider Operations

Forms for New Providers

Join The VNSNY CHOICE Network

Thank you for your interest in joining our CHOICE Provider Network. To get started, please submit your request for participation.

Forms for Current Providers

CDPAS Recertification – Physician Order Form

CHOICE Total and MLTC 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: Form

Demographic Update Form

Participating PCPs and Specialists: Here’s a quick and easy way to let us know about changes to your information!

EFT Request Form

To set up EFT payments, fill out this VNSNY CHOICE EFT Request Form by clicking on the link above.
Please note: in order to begin receiving EFT payments and remittances, you will also need to enroll with Availity to receive ERA files. See Electronic Payment for Providers for details.

Provider Claim Dispute Form

Use this form to submit your claims disputes online. A VNSNY CHOICE representative will get back to you shortly.

Delegated Roster Submissions

Delegated entities are required to submit monthly/quarterly provider rosters.

Visit our Credentialing Page for more information.

Prior Authorization Request Forms

Request for Medicare Prescription Drug Coverage Determination –
PDF Form

Request for Medicare Prescription Drug Coverage Redetermination

New York State Medicaid Prior Authorization Request Form for Prescriptions

Medicare Prior Authorization Requirements

Pre-Authorization Request Form for VNSNY CHOICE Managed Long Term Care Plans

High-Risk Non-Benzodiazepine Medications

Skeletal Muscle Relaxants

RHIO Consent Forms

Authorization for Access to Patient/Member Information Through Health Information Exchanges

Health Information Exchange Fact Sheet