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, Carewell SEIU 503 must have your name, gender, Social Security number, birth date, 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.

 

  1. Submit the form above to update your information with Carewell SEIU 503.
  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 online forms are generally available in Spanish, Russian, Vietnamese, Simplified Chinese, Arabic, Korean, and Somali. 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

      Use this form to acknowledge that you have been offered Carewell SEIU 503 Dental, Vision+Hearing, and Employee Assistance Program (EAP) coverage and are declining this coverage.

      Access Form

      Eligibility and Reimbursement Appeal Form

      Use this form and either fill out the field explaining why you are requesting an appeal or upload an explanation letter. Reimbursement appeals must be accompanied by supporting documentation such as an Explanation of Benefits (EOB) or proof of payment.

      Access Form

      Vision + Hearing

      Ameritas Vision (LASIK only) Reimbursement Claim Form

      PDF Form

      Ameritas Hearing Reimbursement Claim Form

      PDF Form

      Benefits Waiver Form

      Use this form to acknowledge that you have been offered Carewell SEIU 503 Dental, Vision+Hearing, and Employee Assistance Program (EAP) coverage and are declining this coverage.

      Access Form

      Eligibility and Reimbursement Appeal Form

      Use this form and either fill out the field explaining why you are requesting an appeal or upload an explanation letter. Reimbursement appeals must be accompanied by supporting documentation such as an Explanation of Benefits (EOB) or proof of payment.

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      VSP Member Reimbursement Form

      Claim reimbursements are accepted online through the VSP portal at vsp.com. You’ll need to create an account first. For questions, please contact VSP at 1-800-877-7195.

      Employee Assistance Program

      Benefits Waiver Form

      Use this form to acknowledge that you have been offered Carewell SEIU 503 Dental, Vision+Hearing, and Employee Assistance Program (EAP) coverage and are declining this coverage.

      Access Form

      Eligibility and Reimbursement Appeal Form

      Use this form and either fill out the field explaining why you are requesting an appeal or upload an explanation letter. Reimbursement appeals must be accompanied by supporting documentation such as an Explanation of Benefits (EOB) or proof of payment.

      Access Form

      Healthcare Cost Assistance

      For Approved Plans

      2024 Annual Paperwork

      Completing the annual paperwork confirms that you understand and agree to the rules of the program as governed by the rules of the Trust. These forms also 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.

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      HIPAA Authorization

      This notice tells you how Carewell SEIU 503 may use and share your health information. It also includes information on your health privacy rights.

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      Statement of Understanding

      This notice is for care providers to acknowledge their responsibilities in receiving Carewell SEIU 503 benefits.

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      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.

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      Valley Insurance Professionals Agent of Record Form

      Fill out this form to designate VIP as your agent of record to represent you and help you manage your insurance policy.

      Access Form

      2024 Non-VIP Annual Paperwork

      Use this form when your Agent of Record is NOT Valley Insurance Professionals (VIP).

      Access Form

      Healthcare Cost Assistance Benefits Request Form

      Fill out this form to request Healthcare Cost Assistance benefits. You must include your Marketplace Eligibility Notice and your premium bill or My Plans and Programs page from your healthcare.gov account to be eligible for this benefit. If you enrolled in an approved plan through Valley Insurance Professionals, you do not need to submit this form.

      Access Form

      Direct Deposit Form

      Sign up to get your premium reimbursements through direct deposit. This is the fastest and safest way to get your payment. You must include a copy of a voided check, bank letter, or bank statement.

      Access Form

      Medical Premium Reimbursement Claim Form

      Use this form for premium reimbursements if you are enrolled with family members on your plan and/or you are eligible to receive a temporary average premium reimbursement (APR) for a non-approved plan. Must be submitted with proof of individual insurance coverage.

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      Ameriflex Reimbursement Claim Form

      Use this form to claim reimbursement when you have paid for an eligible cost out of your own funds instead of using the Benefit Convenience Card (BCC). You can also use this form if you need to claim reimbursement for net monthly premium for qualifying individual plans purchased through the Marketplace. Please follow the instructions that are included on the online form.

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      Advance Premium Tax Credit Adjustment Form

      Use this form if your income is different than what you reported to the IRS on your Marketplace application. The form will be used to help us determine if we can assist you to pay the amount you have not yet paid or if you received a tax credit overpayment. You must submit it with supporting tax documents.

      Access Form

      Eligibility and Reimbursement Appeal Form

      Use this form and either fill out the field explaining why you are requesting an appeal or upload an explanation letter. Reimbursement appeals must be accompanied by supporting documentation such as an Explanation of Benefits (EOB) or proof of payment.

      Access Form

      Overpayment Notice Appeal Form

      Use this form to appeal an Overpayment Notice from Carewell SEIU 503.

      Access Form

      Healthcare Cost Assistance

      For Medicare

      Ameriflex Reimbursement Claim Form

      Use this form to claim reimbursement when you have paid for an eligible cost out of your own funds instead of using the Benefit Convenience Card (BCC). You can also use this form if you need to claim reimbursement for net monthly premium for qualifying individual plans purchased through the Marketplace. Please follow the instructions that are included on the online form.

      Access Form

      Carewell Medicare Paperwork

      Fill out this paperwork when you first transition to Medicare coverage to see if you are eligible for Healthcare Cost Assistance. Completing this paperwork confirms that you understand and agree to the rules of the program as governed by the rules of the Trust. Please note: you’ll need to fill it out again any time a change in plans is made.

      Access Form

      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.

      Access Form

      Direct Deposit Form

      Sign up to get your premium reimbursements through direct deposit. This is the fastest and safest way to get your payment. You must include a copy of a voided check, bank letter, or bank statement.

      Access Form

      Medicare Premium Reimbursement Claim Form

      Use this form to get your Medicare premium reimbursed—for example, monthly premiums for Medicare Part B, monthly premiums for Medicare Part D, Supplement, or Advantage plans.

      Access Form

      Eligibility and Reimbursement Appeal Form

      Use this form and either fill out the field explaining why you are requesting an appeal or upload an explanation letter. Reimbursement appeals must be accompanied by supporting documentation such as an Explanation of Benefits (EOB) or proof of payment.

      Access Form

      Overpayment Notice Appeal Form

      Use this form to appeal an Overpayment Notice from Carewell SEIU 503.

      Access Form

      Paid Time Off 

      PTO Benefits Request Packet

      If you have 8 hours or more of accumulated PTO, use this form to request payment of your PTO benefits.

      Use MyCarewell503 to complete the form

      Form W-9

      To become eligible for PTO benefits, you must send us a completed and signed Form W-9, if you haven’t already done so. Please note: the PTO benefit is taxable income.

      Use MyCarewell503 to complete the form

      Direct Deposit Form

      Sign up to get your reimbursements and PTO benefits through direct deposit. This is the fastest and safest way to get your payment. You must include a copy of a voided check, bank letter, or bank statement.

      Use MyCarewell503 to complete this form

      Designation of Beneficiary Form

      Complete this form if you would like to name a person to receive your unclaimed PTO benefit in the event of your death.

      Use MyCarewell503 to complete this form

      Overpayment Notice Appeal Form

      Use this form to appeal an Overpayment Notice from Carewell SEIU 503.

      Access Form

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