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*
2018 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)
Download the Request for Redetermination of Medicare Prescription Drug Denial (PDF) for SWH Whole Health

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

Request for Medicare Part D Prescription Drug Coverage Determination (PDF) for SWH Whole Health in ENGLISH
Request for Medicare Part Prescription Drug Coverage Determination (PDF) for SWH Whole Health in SPANISH
Request for Medicare Part Prescription Drug Coverage Determination (PDF) for SWH Whole Health in CHINESE

Medicare Reconsideration Request Form (PDF)

Prior Authorization Forms

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

Drug Coverage Determination Form (PDF) for SWH Whole Health in ENGLISH
Drug Coverage Determination Form (PDF) for SWH Whole Health in SPANISH
Drug Coverage Determination Form (PDF) for SWH Whole Health in CHINESE

Download the Senior Whole Health of New York 2018 Prior Authorization Criteria (PDF) — Effective April 1, 2018
Download the SWH Whole Health FIDA Plan 2018 Prior Authorization Criteria (PDF) — Effective April 1, 2018

Managed Long Term Care (MLTC) Forms

MLTC Enrollment Application & Agreement

SWH Whole Health FIDA Plan

To learn more about the FIDA Program, your options, or how to enroll in SWH Whole Health FIDA Plan call the New York Enrollment Broker at 1-855-600-FIDA, or TTY/TDD users dial 1-888-329-1541, Monday through Friday 8:30 a.m. - 8:00 p.m. and Saturdays 10 a.m. - 6 p.m., or visit nymedicaidchoice.com.*

*By clicking on this link you will be leaving the Senior Whole Health of New York website.

Providers