Member Forms

Below you will find links to various forms and other documents that SelectHealth from VNSNY CHOICE members may need.

Please call Member Services if you need additional information.
 
1-866-469-7774
(TTY: 711)
8 am to 6 pm, Monday – Friday
 
Authorization for Release of Health Information and Confidential HIV Related Info (EnglishSpanish)
 
Health Care Proxy (English, Spanish)
 
Notice of Privacy Practices (EnglishSpanish)

Prior Authorization Request Form (English)

Check below for forms and fact sheets about Health Information Exchanges and Regional Health Information Organizations.

  • Health Information Exchange Fact Sheet (EnglishSpanish)
  • Authorization for Access to Patient/Member Information Through a Health Information Exchange Organization (EnglishSpanish)

Last updated 3/20/2020

 

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