You are on primary menu. Click to skip to content
Senior Whole Health – New York
Mobile Navigation
  • About Us
    • About Senior Whole Health of New York
    • Our Products
    • Leadership
    • Careers
  • Enrollment and Renewal
    • Why Choose Us?
    • Am I Eligible?
    • Enroll Now
    • What to Expect
    • How do I Renew?
  • For Members
    • MAP Members
      • Benefits and Services
        • Pharmacy and Prescription Benefits
      • Member Resources
      • How do I?
    • MLTC Members
      • Member Materials and Forms
      • Member Resources
      • How do I?
    • Quality
  • For Providers
    • Join our Network
    • Provider Materials
    • How to Work with Us
    • Forms
  • Find a Doctor or Pharmacy
    • Find a Doctor
    • Find a Pharmacy
Contact
Portal Access:
  • Provider
  • About Us
    • About Senior Whole Health of New York
    • Our Products
    • Leadership
    • Careers
  • Enrollment and Renewal
    • Why Choose Us?
    • Am I Eligible?
    • Enroll Now
    • What to Expect
    • How do I Renew?
  • For Members
    • MAP Members
    • MLTC Members
    • Quality
  • For Providers
    • Join our Network
    • Provider Materials
    • How to Work with Us
    • Forms
  • Find a Doctor or Pharmacy
    • Find a Doctor
    • Find a Pharmacy
Portal Access:
  • Provider
Contact
You are on secondary menu. Skip to article content

In This Section

  • Join our Network
  • Provider Materials
  • How to Work with Us
  • Forms
  • Quality
  1. Home
  2. For Providers

Forms

Waiver of Liability Form

W-9 Form

PCP Assessment Form

Appointment of Representative Form

Payment Dispute and Adjustment Request Form

Online Request for Medicare Part D Prescription Drug Coverage Determination 

Online Request for Medicare Part D Redetermination 

Request for Redetermination of Medicare Prescription Drug Denial

FDR Annual Compliance Attestation

Rx Coverage Determination Form

Looking for more?
  • Magellan Complete Care

H5992/MLTC_2021_17327

Website updated 1/15/2021

Senior Whole Health of New York NHC is an HMO SNP plan with a Medicare Advantage contract and a contract with the New York Medicaid program. Enrollment depends on annual contract renewal.

Senior Whole Health of New York is a health plan with a contract with the New York Medicaid program.

Careers
facebook
  • Disclaimer
  • Privacy Policy
  • Terms of Use
  • Nondiscrimination
  • Languages
©2020 Magellan Health, Inc. All Rights Reserved.
Print
  • Español
  • 中文 (简体)