Ma u baahan tahay inaad iska diiwaangeliso ama aad cusbooneysiiso ceymiskaaga caafimaadka ee 2022? Isdiiwaangeli ka hor Diseembar 15 si aad u hesho ceymis dhaqangal noqda Janaayo 1, 2022.

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

Wixii ah Qorshooyinka Loo ansixiyay
Medicare

Wakhtiiga Fasaxa Lacagta leh
Kheyraadka COVID-19

Muhiim – Xogtaada mar kasta ha ahaato mida saxda ah

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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. 

  1. Submit the form above to update your information with the Benefits Administrative Office
  2. 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

        Foom Dijitool ah

        Foomka Racfaanka U-qalmitaanka iyo Lacag-celinta

        Foom Dijitool ah

        Must be submitted with a letter explaining why you are requesting an appeal.

        Araga + Maqalka

        Foomka Sheegashada Lacag Celinta Aragga Ameritas (kaliya LASIK)

        Foom PDF ah

        Foomka Sheegashada Lacag Celinta Maqalka ee Ameritas

        Foom PDF ah

        Foomka Ka dhaafitaanka Dheefaha

        Foom Dijitool ah

        Foomka Racfaanka U-qalmitaanka iyo Lacag-celinta

        Foom Dijitool ah

        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

        Foom Dijitool ah

        Foomka Racfaanka U-qalmitaanka iyo Lacag-celinta

        Foom Dijitool ah

        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

        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.

        2022 HIPAA Authorization

        Digital Form

        2022 Statement of Understanding

        Digital Form

        2022 RISE Partnership Community Assistance Consent Form

        Digital Form

        2022 OHA Community Assistance Consent Form

        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.

        2021 Warqadaha Sannadlaha ah

        Foom Dijitool 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

        Foom Dijitool ah

        Foomka Lacag dhigashada tooska ah

        Foom Dijitool ah

        Must be submitted with a copy of a voided check.

        Foomka Sheegashada Lacag-celinta Caafimaadka

        Foom Dijitool ah

        Must be submitted with a copy of Explanation of Benefits or your bill.

        Foomka Lacag-celinta ee Ameriflex

        Foom Dijitool ah

         Foomka Kharashka Dib-u-habaynta Lacag-celinta Sare

        Foom Dijitool ah

        Must be submitted with supporting tax documents.

        Foomka Racfaanka U-qalmitaanka iyo Lacag-celinta

        Foom Dijitool ah

        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

        Foom Dijitool ah

        Warqaddaha Medicare

        Foom Dijitool ah

        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 Lacag dhigashada tooska ah

        Foom Dijitool ah

        Must be submitted with a copy of a voided check.

        Foomka Sheegashada Lacag-celinta Medicare

        Foom Dijitool ah

        Must be submitted with a copy of your premium bill.

        Foomka Racfaanka U-qalmitaanka iyo Lacag-celinta

        Foom Dijitool ah

        Must be submitted with a letter explaining why you are requesting an appeal.

        Wakhtiiga Fasaxa Lacagta leh 

        Xirmada Codsiga Dheefta PTO

        Foom Dijitool ah

        Foomka Lacag dhigashada tooska ah

        Foom Dijitool ah

        Must be submitted with a copy of a voided check.

        Kheyraadka COVID-19

        Foomka Codsiga Dheefta COVID-19 ee PTO

        Foom Dijitool ah

        For hours lost due to COVID-19 after January 1, 2021.

        Warqadda Shaqaalaha Lagama Maarmaanka ah

        Foom Dijitool ah

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        Hagaajinta cookies-ka ee websaydhkan waxaa loogu talagalay inay "oggolaadaan cookies-ka" si ay kuu siiyaan waayo-aragnimada sahminta ee ugu macquulsan. Haddii aad sii wado inaad isticmaasho websaydhkan adiga oo aan baddelin hagaajinta cookie-gaaga ama haddii aad gujiso "Accept" ("Aqbal") ee hoose markaas waxaad oggolaatay midan. Si aad wax badan uga barato siyaasadeena cookie-ga iyo sida aan u maareyno macluumaadka gaarka ah ee laga yaabo inaad ku soo gudbiso websaydhkan, fadlan arag Qaanuunka Arrimaha Khaaska ah.

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