A part of the Visiting Nurse Service of New York »

Welcome to VNS CHOICE: An Affiliate of the Visiting Nurse Service of New York

For more information or to enroll, call:. 1-866-VNS-0047 (TTY/TDD users: 1-888-844-5530)
Monday-Friday, 8 AM to 8 PM

VNS CHOICE Medicare Enrollment Form

Please complete the following form to the best of your ability. A VNS CHOICE Medicare representative will contact you if any information is missing.

Enrollment Form

Please select the VNS CHOICE Medicare Plan in which you would like to enroll:

VNS CHOICE Option 1 (HMO)
VNS CHOICE Option 2 (HMO)
VNS CHOICE Option 5 (HMO)

Personal Information

Last Name:
First Name:
Middle Initial:
Salutation:
Date of Birth:
Member's Gender:

Contact Information

Member's Phone Number:
Email Address:
Language Spoken:

Permanent Residence

Street Address:
Secondary Address (Apt):
City:
State:
Zip/Postal Code:
County:

Mailing Address

Mailing Address:
Secondary Mailing Address (Apt):
City:
State:
Zip/Postal Code:
County:

Emergency Contact

Emerergency Contact Name:
Emergency Phone Number:
Relationship to you:

Your Medicare Insurance Information

Please take out your Medicare Card to complete this section. Please fill in these fields so that they match your red, white and blue Medicare card.

Medicare Card Holder's Name:
Medicare Card Holder's Gender:
Medicare Claim Number:
Medicare Part A Effective Date:
Medicare Part B Effective Date:

Your Plan Premium Option

If we determine that you owe a late enrollment penalty, we need to know how you would prefer to pay it. You can pay by mail each month.

You also can pay your monthly plan premium by mail each month. You can also choose to pay your premium by automatic deduction from your Social Security benefit check each month.

People with limited incomes may qualify for extra help to pay for their prescription drug costs. If eligible, Medicare could pay for 75 percent or more of drug costs, including monthly prescription drug premiums, annual deductibles and coinsurance. Additionally, those who qualify will not be subject to the coverage gap or a late enrollment penalty. Many people are eligible for these savings and don't even know it. For more information about this extra help, contact your local Social Security office, or call Social Security at 1-800-772-1213. TTY users should call 1-800-325-0778. You can also apply for extra help online at www.socialsecurity.gov/prescriptionhelp.

If you qualify for extra help with your Medicare prescription drug coverage costs, Medicare will pay all or part of your plan premium. If Medicare pays only a portion of this premium, we will bill you for the amount that Medicare doesn't cover.

If you don't select a payment option, you will get a bill each month.

Please select a premium payment option: Receive a Bill or Automatic Deduction from your monthly Social Security benefit check.

Note for Automatic Deduction: The Social Security deduction may take two or more months to begin. In most cases, the first deduction from your Social Security benefit check will include all premiums due from your enrollment effective date up to the point withholding begins.

Please read and answer these important questions

Do you have End Stage Renal Disease (ESRD)?

Some individuals may have other drug coverage, including other private insurance, TRICARE, Federal employee health benefits coverage, VA benefits, or State pharmaceutical assistance programs.

Will you have other prescription drug coverage in addition to VNS CHOICE Medicare?

If you answered yes to the previous question, please answer the following questions:

Name of other coverage/drug:
ID # for this coverage:
Group # for this coverage:

Are you a resident in a long-term care facility, such as a nursing home?

Please answer the following questions:

Long Term Care Facility Name:
Facility Address:
Facility City:
Facility State:
Facility Zip Code:
Facility Phone:

Are you enrolled in your State Medicaid Program?

Medicaid Number:

Do you or your spouse work?

Please choose the name of a Primary Care Physician (PCP), clinic or health center from the provider directory:


Provider First Name:
Provider Last Name:
Provider ID #:

Please select one of the options below if you would prefer us to send you information in a language other than English or in another format:

Please contact VNS CHOICE Medicare at 1-866-783-1444 (TTY users should call 1-888-844-5530) if you need information in another format or language than what we listed above. Our office hours are Monday through Friday from 8:00 AM to 8:00 PM.

STOP: Please read this important information

If you currently have health coverage from an employer or union, joining VNS CHOICE Medicare could affect your employer or union health benefits. You could lose your employer or union health coverage if you join VNS CHOICE Medicare. Read the communications your employer or union sends you. If you have questions, visit their website, or contact the office listed in their communications. If there is no information on whom to contact, your benefits administrator or the office that answers questions about your coverage can help.

Please Read and Sign Below

By completing this enrollment application, I agree to the following by initialing:

VNS CHOICE Medicare is a Medicare Advantage plan and has a contract with the Federal government. I will need to keep my Medicare Parts A and B. I can be in only one Medicare Advantage plan at a time and I understand that my enrollment in this plan will automatically end my enrollment in another Medicare health plan or prescription drug plan. It is my responsibility to inform you of any prescription drug coverage that I have or may get in the future. Enrollment in this plan is voluntary. Once I enroll, I may leave this plan or make changes only at certain times of the year when an enrollment period is available (example: November 15 - December 31 of every year), or under certain circumstances. (Individuals with Medicaid can disenroll from a plan at any time during the year.)