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, 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.

 

  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 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.

      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

      2023 Renewal questionnaire

      Digital Form

      2023 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.

      HIPAA Authorization

      Digital Form

      Statement of Understanding

      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

      OHA Community Partnership Consent Form

      Digital Form

      2023 Non-VIP AoR annual paperwork

      Digital Form

      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

      Form W-9

      Digital Form

      Direct Deposit Form

      Digital Form

      Must be submitted with a copy of a voided check.

      Designation of Beneficiary Form

      Digital 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.

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