Participant Forms

Important News: The New York State Department of Health ended the Fully Integrated Duals Advantage (FIDA) program on Dec. 31, 2019. FIDA plans are not accepting any new enrollees or plan transfers in 2020. 

Below you will find links to various forms and other documents for VNSNY CHOICE FIDA Complete participants.

Please call Participant Services if you need additional information.
(TTY: 711)
7 days a week, 8 am - 8 pm
Release Health Info Forms  (EnglishSpanish)
Personal Medication List (English)

Your Prescription Mail Order Form/Brochure (English, Spanish)

Appointment of Representative Form (EnglishSpanish)
If you want a friend, relative, or other person to be your representative, you can either complete this “Appointment of Representative” form and give us a copy of the signed form or you can write and sign a letter indicating who you want to be your representative and give us a copy of the letter. You can give us a copy of the form or letter or mail it to VNSNY CHOICE FIDA Complete, 220 East 42nd Street, 3rd floor, New York, NY 10017.
Appointing Your Health Care Proxy (EnglishSpanish)
New York Advance Directive Planning Guide (English)
Request for CHOICE FIDA Complete Prescription Drug Determination Form (English)
Request for CHOICE FIDA Complete Prescription Drug Redetermination Form (English)
Opioid Prior Authorization Request Form (English)

VNSNY CHOICE FIDA Complete is a managed care plan that contracts with both Medicare and the New York State Department of Health (Medicaid) to provide benefits of both programs to Participants through the Fully Integrated Duals Advantage (FIDA) Demonstration.

The State of New York has created a Participant Ombudsman Program called the Independent Consumer Advocacy Network (ICAN) to provide Participants free, confidential assistance on any services offered by VNSNY CHOICE FIDA Complete. ICAN may be reached toll-free at 1-844-614-8800 or online at (TTY users call 711, then follow the prompts to dial 844-614-8800.)

ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al 1-866-783-1444 (TTY: 711).

You can get this information for free in other formats, such as Braille or audio CD. Call 1-866-783-1444 (TYY: 711) during 8 am – 8 pm, 7 days a week. The call is free.

Last updated 1/2/2020

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