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 Program
Healthcare Cost Assistance

For Approved Plans
For Medicare

Paid Time Off

Important – Keep your information up to date

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”

        Our digital forms are generally available in Spanish, Russian, Vietnamese, and Simplified Chinese. To fill out the form in your preferred language, click on the US flag in the top right corner of the form, and then select your preferred language.

        Dental

        Benefits Waiver Form

        Digital Form

        Eligibility and Reimbursement Appeal Form

        Digital Form

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

        Temporary Dental Out-Of-Pocket Reimbursement Enrollment Form

        Digital Form

        Vision + Hearing

        Ameritas Vision (LASIK only) Reimbursement Claim Form

        PDF Form

        Ameritas Hearing Reimbursement Claim Form

        PDF Form

        Benefits Waiver Form

        Digital Form

        Eligibility and Reimbursement Appeal Form

        Digital Form

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

        VSP Member Reimbursement Form

        Claim reimbursements electronically through the VSP portal at vsp.com. You’ll have to create an account first. 

        Employee Assistance Program

        Benefits Waiver Form

        Digital Form

        Eligibility and Reimbursement Appeal Form

        Digital Form

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

        Healthcare Cost Assistance

        For Approved Plans

        2022 Annual Paperwork

        Digital Form

        These forms give the Carewell SEIU 503 Benefits team permission to assist you with enrolling in and maintaining your healthcare coverage. This paperwork is not an application for health insurance.

        2022 HIPAA Authorization

        Digital Form

        2022 Statement of Understanding

        Digital Form

        2022 RISE Partnership Community Assistance Consent Form

        Digital Form

        2022 OHA Community Assistance Consent Form

        Digital Form

        Consent to Release Information Form

        Digital Form

        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.

        VIP Agent of Record Form

        Digital Form

        2021 Annual Paperwork

        Digital Form

        These forms give the Carewell SEIU 503 Benefits team permission to assist you with enrolling and maintaining your healthcare coverage. This paperwork is not an application for health insurance.

        Enrollment Information Form

        Digital Form

        Direct Deposit Form

        Digital Form

        Must be submitted with a copy of a voided check.

        Medical Reimbursement Claim Form

        Digital Form

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

        Ameriflex Reimbursement Form

        Digital Form

         Premium Adjustment Reimbursement Form

        Digital Form

        Must be submitted with supporting tax documents.

        Eligibility and Reimbursement Appeal Form

        Digital Form

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

        Healthcare Cost Assistance

        For Medicare

        Ameriflex Reimbursement Form

        Digital Form

        Medicare Healthcare Cost Assistance Paperwork

        Digital Form

        Consent to Release Information Form

        Digital Form
        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

        Must be submitted with a copy of a voided check.

        Medicare Reimbursement Claim Form

        Digital Form

        Must be submitted with a copy of your premium bill.

        Eligibility and Reimbursement Appeal Form

        Digital Form

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

        Paid Time Off 

        PTO Benefit Request Packet

        Digital Form

        Direct Deposit Form

        Digital Form

        Must be submitted with a copy of a voided check.

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