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.
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
Demographic Update Form
Participating PCPs and Specialists: Here’s a quick and easy way to let us know about changes to your information!
Provider Claim Dispute Form
Use this form to submit your claims disputes online. A VNSNY CHOICE representative will get back to you shortly.
Prior Authorization Request Forms
Request for Medicare Prescription Drug Coverage Determination
Download:
Coverage Determination Form
Request for Medicare Prescription Drug Coverage Redetermination
Download:
Redetermination Form
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
Download:
Pre-Authorization Request Form
Opioids
Download:
Opioid Prior Authorization Request Form
Diclofenac (Topical)
High-Risk Medications
High-Risk Non-Benzodiazepine Medications
Skeletal Muscle Relaxants
Lidocaine Patch and Ointment
Hepatitis C Antivirals
Download:
Hepatitis C Antivirals Request Form