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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 us at 1-888-783-1444, 8 am – 8 pm, 7 days a week. TTY users should call 711.

Help Us Help You Better!

From March through May, Medicare will be sending out surveys to random members of Medicare plans like VNSNY CHOICE Total. The survey, called the Consumer Assessment of Healthcare Providers and Systems or CAHPS, is a consumer satisfaction survey. The survey is completely anonymous and will not affect your benefits in any way.

If you receive a survey about your CHOICE Total plan, please help us improve our services by filling it out. We want to be the best CHOICE for you and your feedback will help us.

Forms and Personal Health Materials

CDPAS Recertification – Physician Order Form

CHOICE 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 six months during CDPAS recertification.

Download: Form

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

Download: English