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, 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.
- 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 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.
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.
Vision + Hearing
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.
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.
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.
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.
Healthcare Cost Assistance
For Approved Plans
2023 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.
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.
Statement of Understanding
This notice is for care providers to acknowledge their responsibilities in receiving Carewell SEIU 503 benefits.
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.
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.
2023 Non-Valley Insurance Professionals Agent of Record annual paperwork + Healthcare Cost Assistance Benefits Request Form
Fill out this form to designate an agent of record other than Valley Insurance Professionals (VIP) to represent you and help you manage your insurance policy. These forms give the Carewell SEIU 503 Benefits team and their partners permission to assist you with enrolling in and maintaining your healthcare coverage.
It also includes the Healthcare Cost Assistance (HCA) Benefits Request Form to request HCA benefits. You must include your Marketplace Eligibility Notice and your premium bill 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.
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 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.
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.
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.
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.
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.
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.
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.
Medicare Healthcare Cost Assistance Paperwork
Fill out this paperwork when you first transition to Medicare coverage. 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.
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.
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.
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.
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.
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.
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.
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.
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.