Select Page

Forms

Listed below are all required forms you’ll need in order to enroll in or renew your Carewell benefits. Forms are organized by benefit or category.

Select a benefit or category to view forms

Dental
Vision + Hearing
Employee Assistance Progam
Healthcare Cost Assistance
Paid Time Off

Important – Keep your information up to date

Update Your Information

Step 1 of 5

  • First
  • Middle
  • Last

To be eligible for Carewell benefits, the Benefit Administrative Office must have your name, gender, Social Security Number, birthdate and current address on file. You should also make sure that your information is up-to-date with the State. Note: Submitting this information will enable the Benefits Administrative Office to enroll you in Carewell SEIU 503 Dental, Vision + Hearing and Employee Assistance Program benefits if you are eligible. 

  1. Submit the form above to update your information with the Benefits Administrative Office
  2. Follow the instructions below to update your personal information with the State depending on what type of worker you are.

    Homecare Worker (HCW)

    Update your address with the local APD/AAA field office. The local HCW Coordinator/Clerk is the appropriate person to connect with.

      ODDS Personal Support Worker (PSW)

      Fill out this Change of Information form (PDF) to make sure DHS has your current information on file.

        OHA Personal Support Worker (PSW)

        Fill out this Provider Information Update Form (PDF) to make sure OHA has your current information on file. Fill out all sections on the form except for these:

        • “Complete this section for an organization, group or agency”
        • “Taxonomy code changes”

        Dental

        Benefits Waiver Form

        Digital Form A

        Review and Appeal Form

        Digital Form B

        Must be submitted with a letter explaining why you are requesting an appeal.

        Vision + Hearing

        Ameritas Vision (LASIK only) Reimbursement Claim Form

        PDF Form A

        Ameritas Hearing Reimbursement Claim Form

        PDF Form B

        Benefits Waiver Form

        Digital Form C

        Review and Appeal Form

        Digital Form D
        Must be submitted with a letter explaining why you are requesting an appeal.

        VSP Member Reimbursement Form

        PDF Form C

        Employee Assistance Program

        Benefits Waiver Form

        Digital Form E

        Review and Appeal Form

        Digital Form F

        Must be submitted with a letter explaining why you are requesting an appeal.

        Healthcare Cost Assistance

        For Approved Plans

        2020 Annual Paperwork: Inside the Kaiser Service Area

        Digital Form GG

        2020 Annual Paperwork: Outside the Kaiser Service Area

        Digital Form GGG

        2020 General Agent of Record Form

        Digital Form G

        2020 HIPPA Form

        Digital Form H

        2020 Kaiser Permanente: Agent of Record Form

        Digital Form I

        2020 Statement of Understanding Form

        Digital Form J

        Ameriflex Reimbursement Form

        PDF Form D

        Community Partner Assistance Form

        Digital Form K

        Consent to Release Form

        Digital Form L

        Fill this out if you need to allow a trusted family member or friend to make inquiries, schedule appointments or confirm information on your behalf.

        Direct Deposit Form

        Digital Form M

        Must be submitted with a copy of a voided check.

        Enrollment Information Form

        Digital Form N

        Medical Reimbursement Claim Form

        Digital Form O

        Must be submitted with a copy of Explanation of Benefits or your bill.

        Oregon Health Authority Consent Form

        Digital Form P

        Review and Appeal Form

        Digital Form Q

        Must be submitted with a letter explaining why you are requesting an appeal

         Premium Adjustment Reimbursement Form

        Digital Form AAA

        Must be submitted with supporting tax documents.

        Healthcare Cost Assistance

        For Medicare

        2020 General Agent of Record Form

        Digital Form R

        2020 HIPPA Form

        Digital Form S

        2020 Statement of Understanding Form

        Digital Form T

        Ameriflex Reimbursement Form

        PDF Form E

        Annual Medicare Paperwork

        Digital Form U

        Community Partner Assistance Form

        Digital Form V

        Consent to Release Form

        Digital Form W

        Fill this out if you need to allow a trusted family member or friend to make inquiries, schedule appointments or confirm information on your behalf.

        Direct Deposit Form

        Digital Form X

        Must be submitted with a copy of a voided check.

        Medicare Reimbursement Claim Form

        Digital Form Y

        Must be submitted with a copy of your premium bill.

        Oregon Health Authority Consent Form

        Digital Form Z

        Review and Appeal Form

        Digital Form AA

        Must be submitted with a letter explaining why you are requesting an appeal

        Paid Time Off 

        PTO Beneficiary Form

        Digital Form BB

        PTO Beneficiary Form & Form W-9

        Digital Form CC

        PTO Benefit Request Form

          Digital Form DD

        Direct Deposit Form

        Digital Form EE

        Must be submitted with a copy of a voided check.

        By continuing to use the site, you agree to the use of cookies. More information.

        The cookie settings on this website are set to "allow cookies" to give you the best browsing experience possible. If you continue to use this website without changing your cookie settings or you click "Accept" below then you are consenting to this. To learn more about our cookie policy and how we handle personal information that you may submit through this website, please see our Privacy Policy.

        Close