Foomamka
Hoos waxaa ku taxan dhammaan foomamka loo baahan yahay si aad isu diiwaan geliso ama aad u cusboonaysiiso dheefahaaga Carewell. Foomamka waxaa lagu habeeyaa dheef ama qayb ahaan.
Dooro dheef ama qayb si aad u aragto foomamka
Ilkaha
Araga + Maqalka
Barnaamijka Caawinta Shaqaalaha
Kaalmada Kharashka Daryeelka Caafimaadka
Wakhtiiga Fasaxa Lacagta leh
Kheyraadka COVID-19
Muhiim – Xogtaada mar kasta ha ahaato mida saxda ah
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.
- Submit the form above to update your information with the Benefits Administrative Office
- Follow the instructions below to update your personal information with the State depending on what type of worker you are.
Shaqaalaha Daryeelka Guriga (HCW)
Cusbooneysii cinwaankaaga xafiiska goobta APD/AAA ee deegaanka. Iskuduwaha/karraaniga HCW ee deegaanka ayaa ah qofka ku haboon in lala xidhiidho.
Shaqaalaha Taageerada Shaqsiyeed ee ODDS
Buuxi Foomkan beddelida Macluumaadka (PDF) si aad u hubiyo in DHS ay ku hayso macluumaadkaaga hadda jira faylka.
Shaqaalaha Taageerada Shaqsiyeed ee OHA
Buuxi Foomkan Cusboonaysiinta Macluumaadka Bixiyaha (PDF) si aad u hubiyo in OHA ay ku hayso macluumaadkaaga hadda jira faylka. Ku buuxi dhammaan qaybaha foomka marka laga reebo kuwan:
- “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.
Ilkaha
Foomka Ka dhaafitaanka Dheefaha
Foomka Racfaanka U-qalmitaanka iyo Lacag-celinta
Must be submitted with a letter explaining why you are requesting an appeal.
Araga + Maqalka
Foomka Sheegashada Lacag Celinta Aragga Ameritas (kaliya LASIK)
Foomka Sheegashada Lacag Celinta Maqalka ee Ameritas
Foomka Ka dhaafitaanka Dheefaha
Foomka Racfaanka U-qalmitaanka iyo Lacag-celinta
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.
Barnaamijka Caawinta Shaqaalaha
Foomka Ka dhaafitaanka Dheefaha
Foomka Racfaanka U-qalmitaanka iyo Lacag-celinta
Must be submitted with a letter explaining why you are requesting an appeal.
Kaalmada Kharashka Daryeelka Caafimaadka
Wixii ah Qorshayaasha La ansixiyay
2022 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.
2022 HIPAA Authorization
2022 Statement of Understanding
2022 RISE Partnership Community Assistance Consent Form
2022 OHA Community Assistance Consent 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.
2021 Warqadaha Sannadlaha ah
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.
Foomka Macluumaadka Diiwaangelinta
Foomka Sheegashada Lacag-celinta Caafimaadka
Must be submitted with a copy of Explanation of Benefits or your bill.
Foomka Lacag-celinta ee Ameriflex
Foomka Kharashka Dib-u-habaynta Lacag-celinta Sare
Must be submitted with supporting tax documents.
Foomka Racfaanka U-qalmitaanka iyo Lacag-celinta
Must be submitted with a letter explaining why you are requesting an appeal.
Kaalmada Kharashka Daryeelka Caafimaadka
Wixii ah Medicare
Foomka Lacag-celinta ee Ameriflex
Warqaddaha Medicare
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.
Foomka Sheegashada Lacag-celinta Medicare
Must be submitted with a copy of your premium bill.
Foomka Racfaanka U-qalmitaanka iyo Lacag-celinta
Must be submitted with a letter explaining why you are requesting an appeal.
Wakhtiiga Fasaxa Lacagta leh
Xirmada Codsiga Dheefta PTO
Foomka W-9
Kheyraadka COVID-19
Foomka Codsiga Dheefta COVID-19 ee PTO
For hours lost due to COVID-19 after January 1, 2021.