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Forms and Personal Health Materials

VNSNY CHOICE Total Forms and Personal Health Materials

Looking for more in-depth information about your VNSNY CHOICE Total (HMO D-SNP) health plan and membership? You’ll find it here, along with forms and other tools and materials to help you make the most of your membership.

If you can’t print them yourself, you can get a printed copy of anything on this page by calling Member Services at 1-888-783-1444, 8 am – 8 pm, 7 days a week. TTY users should call 711.

Forms and Personal Health Materials

Authorization for Release of Health Information Pursuant to HIPAA

Health Care Proxy

Authorization for Release of Health Information

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: VNSNY CHOICE Total 220 East 42nd Street, 3rd floor, New York, NY 10017

Health Information Exchange Fact Sheet

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

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

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