Forms New York

Commonly Requested Forms

Appointment of Representative Form* — (For use with organizational determinations, appeals and grievances ONLY)
Authorization to Release Personal Health Information to a Friend or Family Member (PDF)
Health Care Proxy*
Download the Senior Whole Health of New York 2020 LIS Premium Summary Chart (PDF).
Download the Senior Whole Health of New York NHC (HMO SNP) Enrollment Application (PDF).
Download the Senior Whole Health of New York NHC (HMO SNP) Enrollment Application in SPANISH (PDF).

Medicare Forms

Medicare Complaint Form*

Online Request for Medicare Part D Redetermination
Download the Request for Redetermination of Medicare Prescription Drug Denial (PDF) for Senior Whole Health of NY NHC (HMO SNP)

Online Request for Medicare Part D Prescription Drug Coverage Determination 

Request for Medicare Part D Prescription Drug Coverage Determination (PDF) for Senior Whole Health of NY NHC (HMO SNP) in ENGLISH

Medicare Reconsideration Request Form (PDF)

Prior Authorization Forms

Drug Coverage Determination Form (PDF) for Senior Whole Health of NY NHC in ENGLISH

Download the Senior Whole Health of New York 2020 Prior Authorization Criteria (PDF).

Managed Long Term Care (MLTC) Forms

MLTC Enrollment Application & Agreement

Providers