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
Paid Time Off
Important – Keep your information up to date
To be eligible for Carewell benefits, Carewell SEIU 503 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 Carewell SEIU 503 to enroll you in Carewell SEIU 503 Dental, Vision + Hearing, and Employee Assistance Program benefits if you are eligible.
- Submit the form above to update your information with Carewell SEIU 503.
- 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
Eligibility and Reimbursement Appeal Form
Must be submitted with a letter explaining why you are requesting an appeal.
Vision + Hearing
Benefits Waiver Form
Eligibility and Reimbursement Appeal 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
Eligibility and Reimbursement Appeal Form
Must be submitted with a letter explaining why you are requesting an appeal.
Healthcare Cost Assistance
For Approved Plans
2023 Renewal questionnaire
2023 Annual Paperwork
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.
HIPAA Authorization
Statement of Understanding
Consent to Release Information 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
OHA Community Partnership Consent Form
2023 Non-VIP AoR annual paperwork
Enrollment Information Form
Medical Reimbursement Claim Form
Must be submitted with a copy of Explanation of Benefits or your bill.
Ameriflex Reimbursement Form
Eligibility and Reimbursement Appeal Form
Must be submitted with a letter explaining why you are requesting an appeal.
Healthcare Cost Assistance
For Medicare
Ameriflex Reimbursement Form
Medicare Healthcare Cost Assistance Paperwork
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.
Eligibility and Reimbursement Appeal Form
Must be submitted with a letter explaining why you are requesting an appeal.
Paid Time Off
PTO Benefit Request Packet
Form W-9
Designation of Beneficiary Form
With this benefit, we urge you to complete the Designation of Beneficiary Form so that the person you choose receives your unclaimed PTO payment in the event of your death.