{"id":221552,"date":"2021-04-06T12:20:59","date_gmt":"2021-04-06T19:20:59","guid":{"rendered":"http:\/\/www.carewellseiu503.org\/%e8%b5%84%e6%ba%90\/%e8%a1%a8%e6%a0%bc\/"},"modified":"2025-12-01T10:20:44","modified_gmt":"2025-12-01T18:20:44","slug":"forms","status":"publish","type":"page","link":"https:\/\/www.carewellseiu503.org\/zh-hans\/resources\/forms\/","title":{"rendered":"\u6ce8\u518c\u548c\u62a5\u9500\u7533\u8bf7\u8868"},"content":{"rendered":"<p>[et_pb_section fb_built=&#8221;1&#8243; custom_padding_last_edited=&#8221;on|phone&#8221; _builder_version=&#8221;4.16&#8243; background_color=&#8221;#ffffff&#8221; background_enable_image=&#8221;off&#8221; background_position=&#8221;bottom_left&#8221; min_height=&#8221;350px&#8221; min_height_tablet=&#8221;100px&#8221; min_height_phone=&#8221;&#8221; min_height_last_edited=&#8221;on|phone&#8221; custom_margin=&#8221;||0px||false|false&#8221; custom_padding=&#8221;50px||0px||false|false&#8221; custom_padding_tablet=&#8221;&#8221; custom_padding_phone=&#8221;0px||||false|false&#8221; 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max_width=&#8221;900px&#8221; custom_margin=&#8221;||0px|||&#8221; custom_padding=&#8221;||40px|||&#8221; global_colors_info=&#8221;{}&#8221;]<\/p>\n<p class=\"p1\"><span style=\"font-weight: 400;\">\u4ee5\u4e0b\u662f\u60a8\u6ce8\u518c\u6216\u7eed\u4fdd\u60a8\u7684 Carewell \u798f\u5229\u5fc5\u987b\u8981\u586b\u5199\u7684\u6240\u6709\u8868\u683c\u3002\u8868\u683c\u662f\u6309\u798f\u5229\u6216\u7c7b\u522b\u8fdb\u884c\u6574\u7406\u7684\u3002 <\/span><\/p>\n<p>[\/et_pb_text][\/et_pb_column][\/et_pb_row][\/et_pb_section][et_pb_section fb_built=&#8221;1&#8243; use_custom_gutter=&#8221;on&#8221; gutter_width=&#8221;2&#8243; specialty=&#8221;on&#8221; custom_padding_last_edited=&#8221;on|desktop&#8221; module_class_1=&#8221;stickyColumn&#8221; module_class=&#8221;stickyRow&#8221; _builder_version=&#8221;4.16&#8243; background_color=&#8221;#f3f3f3&#8243; custom_margin=&#8221;0px||||false|false&#8221; custom_padding=&#8221;0px||||false|false&#8221; custom_padding_tablet=&#8221;15px||||false|false&#8221; 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_builder_version=&#8221;4.16&#8243; _module_preset=&#8221;default&#8221; disabled=&#8221;on&#8221; global_colors_info=&#8221;{}&#8221; collapsed=&#8221;on&#8221;][et_pb_column_inner saved_specialty_column_type=&#8221;3_4&#8243; _builder_version=&#8221;4.16&#8243; _module_preset=&#8221;default&#8221; global_colors_info=&#8221;{}&#8221;][et_pb_text _builder_version=&#8221;4.21.0&#8243; _module_preset=&#8221;default&#8221; global_colors_info=&#8221;{}&#8221;]<\/p>\n<p><strong>\u6211\u4eec\u7684\u5728\u7ebf\u8868\u683c\u901a\u5e38\u63d0\u4f9b\u897f\u73ed\u7259\u8bed\u3001\u4fc4\u8bed\u3001\u8d8a\u5357\u8bed\u3001\u7b80\u4f53\u4e2d\u6587\u3001\u963f\u62c9\u4f2f\u8bed\u3001\u97e9\u8bed\u548c\u7d22\u9a6c\u91cc\u8bed\u7248\u672c\u3002\u8981\u4f7f\u7528\u60a8\u7684\u9996\u9009\u8bed\u8a00\u586b\u5199\u8868\u683c\uff0c\u8bf7\u70b9\u51fb\u4f4d\u4e8e\u8868\u683c\u53f3\u4e0a\u89d2\u7684\u7f8e\u56fd\u56fd\u65d7\uff0c\u7136\u540e\u9009\u62e9\u60a8\u7684\u9996\u9009\u8bed\u8a00\u3002<\/strong><\/p>\n<p>[\/et_pb_text][et_pb_image src=&#8221;https:\/\/www.carewellseiu503.org\/wp-content\/uploads\/EN-2024-Annual-Paperwork-Image.png&#8221; title_text=&#8221;EN-2024-Annual-Paperwork-Image&#8221; _builder_version=&#8221;4.21.0&#8243; _module_preset=&#8221;default&#8221; global_colors_info=&#8221;{}&#8221;][\/et_pb_image][\/et_pb_column_inner][\/et_pb_row_inner][et_pb_row_inner module_id=&#8221;dentalanchor&#8221; _builder_version=&#8221;4.16&#8243; custom_padding=&#8221;3px||2px|||&#8221; locked=&#8221;off&#8221; global_colors_info=&#8221;{}&#8221; collapsed=&#8221;on&#8221;][et_pb_column_inner saved_specialty_column_type=&#8221;3_4&#8243; _builder_version=&#8221;4.16&#8243; global_colors_info=&#8221;{}&#8221;][et_pb_text module_id=&#8221;dentalanchor&#8221; _builder_version=&#8221;4.16&#8243; global_colors_info=&#8221;{}&#8221;]<\/p>\n<h2>\u7259\u79d1<\/h2>\n<p>[\/et_pb_text][\/et_pb_column_inner][\/et_pb_row_inner][et_pb_row_inner use_custom_gutter=&#8221;on&#8221; gutter_width=&#8221;1&#8243; custom_padding_last_edited=&#8221;on|phone&#8221; disabled_on=&#8221;off|off|off&#8221; module_class=&#8221;twoColumns&#8221; _builder_version=&#8221;4.16&#8243; 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_builder_version=&#8221;4.23.1&#8243; background_color=&#8221;#FFFFFF&#8221; max_width=&#8221;1000px&#8221; module_alignment=&#8221;center&#8221; height=&#8221;100%&#8221; custom_margin=&#8221;0px||||false|false&#8221; custom_padding=&#8221;15px|15px|15px|15px|true|true&#8221; border_width_all=&#8221;1px&#8221; border_color_all=&#8221;#f3f3f3&#8243; global_colors_info=&#8221;{}&#8221;]<\/p>\n<h5 style=\"text-align: left;\">Benefits Waiver Form\uff08\u798f\u5229\u5f03\u6743\u4e66\uff09<\/h5>\n<p>\u4f7f\u7528\u6b64\u8868\u683c\u5373\u8868\u793a\u60a8\u627f\u8ba4\u5df2\u83b7\u5f97 Carewell SEIU 503 \u7259\u79d1\u3001\u89c6\u529b+\u542c\u529b\u548c\u5458\u5de5\u8f85\u52a9\u8ba1\u5212 (EAP) \u4fdd\u9669<u>\u5e76\u62d2\u7edd\u6b64\u4fdd\u9669<\/u>\u3002<br \/>[et_pb_section global_module=\"274298\"][\/et_pb_section]<\/p>\n<p>[\/et_pb_text][et_pb_text _builder_version=&#8221;4.27.4&#8243; text_line_height=&#8221;1.5em&#8221; background_color=&#8221;#ffffff&#8221; max_width=&#8221;1000px&#8221; module_alignment=&#8221;center&#8221; custom_margin=&#8221;0px||||false|false&#8221; custom_padding=&#8221;15px|15px|15px|15px|true|true&#8221; border_width_all=&#8221;1px&#8221; border_color_all=&#8221;#f3f3f3&#8243; global_colors_info=&#8221;{}&#8221;]<\/p>\n<h5 style=\"text-align: left;\">Eligibility and Reimbursement Appeal Form\uff08\u8d44\u683c\u548c\u62a5\u9500\u7533\u8bc9\u8868\uff09<\/h5>\n<p>\u4f7f\u7528\u6b64\u8868\u683c\uff0c\u586b\u5199\u89e3\u91ca\u60a8\u4e3a\u4ec0\u4e48\u8981\u6c42\u7533\u8bc9\u7684\u5b57\u6bb5\u6216\u8005\u4e0a\u4f20\u4e00\u5c01\u89e3\u91ca\u4fe1\u3002\u62a5\u9500\u7533\u8bc9\u5fc5\u987b\u9644\u6709\u652f\u6301\u6587\u6863\uff0c\u5982 Explanation of Benefits\uff08\u533b\u7597\u8d39\u5bf9\u8d26\u5355\uff0cEOB\uff09\u6216\u4ed8\u6b3e\u8bc1\u660e\u3002<\/p>\n<p><a class=\"noUnderline\" href=\"https:\/\/risepartnership.jotform.com\/212296895694070?language=zh\" target=\"_blank\" rel=\"noopener noreferrer\"><i class=\"fas fa-align-left\"><\/i><span style=\"text-decoration: underline;\">\u8bbf\u95ee\u8868\u683c<\/span><\/a><\/p>\n<p>[\/et_pb_text][\/et_pb_column_inner][\/et_pb_row_inner][et_pb_row_inner module_id=&#8221;visionanchor&#8221; _builder_version=&#8221;4.16&#8243; custom_padding=&#8221;3px||2px|||&#8221; locked=&#8221;off&#8221; global_colors_info=&#8221;{}&#8221; collapsed=&#8221;on&#8221;][et_pb_column_inner saved_specialty_column_type=&#8221;3_4&#8243; _builder_version=&#8221;4.16&#8243; global_colors_info=&#8221;{}&#8221;][et_pb_text module_id=&#8221;visionhearinganchor&#8221; _builder_version=&#8221;4.16&#8243; global_colors_info=&#8221;{}&#8221;]<\/p>\n<h2>\u89c6\u529b + \u542c\u529b<\/h2>\n<p>[\/et_pb_text][\/et_pb_column_inner][\/et_pb_row_inner][et_pb_row_inner use_custom_gutter=&#8221;on&#8221; gutter_width=&#8221;1&#8243; _builder_version=&#8221;4.16&#8243; custom_margin=&#8221;||0px||false|false&#8221; custom_padding=&#8221;0px||0px||false|false&#8221; global_colors_info=&#8221;{}&#8221; collapsed=&#8221;on&#8221;][et_pb_column_inner saved_specialty_column_type=&#8221;3_4&#8243; _builder_version=&#8221;4.16&#8243; global_colors_info=&#8221;{}&#8221;][et_pb_text _builder_version=&#8221;4.27.4&#8243; background_color=&#8221;#ffffff&#8221; max_width=&#8221;1000px&#8221; module_alignment=&#8221;center&#8221; height=&#8221;100%&#8221; custom_margin=&#8221;0px||||false|false&#8221; custom_padding=&#8221;15px|15px|15px|15px|true|true&#8221; border_width_all=&#8221;1px&#8221; border_color_all=&#8221;#f3f3f3&#8243; locked=&#8221;off&#8221; global_colors_info=&#8221;{}&#8221;]<\/p>\n<h5 style=\"text-align: left;\">Ameritas Vision (LASIK only) Reimbursement Claim Form\uff08Ameritas \u89c6\u529b [\u4ec5\u9650 LASIK] \u62a5\u9500\u7533\u8bf7\u8868\uff09<\/h5>\n<p><a href=\"https:\/\/www.carewellseiu503.org\/wp-content\/uploads\/Lasik-claims-form.pdf\" class=\"noUnderline\" target=\"_blank\" rel=\"noopener\"> <i class=\"fas fa-file-pdf\"><\/i> <span style=\"text-decoration: underline;\">PDF \u8868\u683c<\/span><\/a><\/p>\n<p>[\/et_pb_text][et_pb_text _builder_version=&#8221;4.27.4&#8243; background_color=&#8221;#ffffff&#8221; max_width=&#8221;1000px&#8221; module_alignment=&#8221;center&#8221; height=&#8221;100%&#8221; custom_margin=&#8221;0px||||false|false&#8221; custom_padding=&#8221;15px|15px|15px|15px|true|true&#8221; border_width_all=&#8221;1px&#8221; border_color_all=&#8221;#f3f3f3&#8243; global_colors_info=&#8221;{}&#8221;]<\/p>\n<h5 style=\"text-align: left;\">Ameritas Hearing Reimbursement Claim Form\uff08Ameritas \u542c\u529b\u62a5\u9500\u7533\u8bf7\u8868\uff09<\/h5>\n<p><a class=\"noUnderline\" href=\"https:\/\/www.carewellseiu503.org\/wp-content\/uploads\/soundcare-claims-form.pdf\" target=\"_blank\" rel=\"noopener\"> <i class=\"fas fa-file-pdf\"><\/i> <span style=\"text-decoration: underline;\">PDF \u8868\u683c<\/span><\/a><\/p>\n<p>[\/et_pb_text][\/et_pb_column_inner][\/et_pb_row_inner][et_pb_row_inner use_custom_gutter=&#8221;on&#8221; gutter_width=&#8221;1&#8243; _builder_version=&#8221;4.16&#8243; custom_margin=&#8221;0px||25px||false|false&#8221; custom_padding=&#8221;0px||0px||false|false&#8221; global_colors_info=&#8221;{}&#8221; collapsed=&#8221;on&#8221;][et_pb_column_inner saved_specialty_column_type=&#8221;3_4&#8243; 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_builder_version=&#8221;4.23.1&#8243; background_color=&#8221;#FFFFFF&#8221; max_width=&#8221;1000px&#8221; module_alignment=&#8221;center&#8221; height=&#8221;100%&#8221; custom_margin=&#8221;0px||||false|false&#8221; custom_padding=&#8221;15px|15px|15px|15px|true|true&#8221; border_width_all=&#8221;1px&#8221; border_color_all=&#8221;#f3f3f3&#8243; global_colors_info=&#8221;{}&#8221;]<\/p>\n<h5 style=\"text-align: left;\">Benefits Waiver Form\uff08\u798f\u5229\u5f03\u6743\u4e66\uff09<\/h5>\n<p>\u4f7f\u7528\u6b64\u8868\u683c\u5373\u8868\u793a\u60a8\u627f\u8ba4\u5df2\u83b7\u5f97 Carewell SEIU 503 \u7259\u79d1\u3001\u89c6\u529b+\u542c\u529b\u548c\u5458\u5de5\u8f85\u52a9\u8ba1\u5212 (EAP) \u4fdd\u9669<u>\u5e76\u62d2\u7edd\u6b64\u4fdd\u9669<\/u>\u3002<br \/>[et_pb_section global_module=\"274298\"][\/et_pb_section]<\/p>\n<p>[\/et_pb_text][et_pb_text _builder_version=&#8221;4.27.4&#8243; text_line_height=&#8221;1.5em&#8221; background_color=&#8221;#ffffff&#8221; max_width=&#8221;1000px&#8221; module_alignment=&#8221;center&#8221; height=&#8221;100%&#8221; custom_margin=&#8221;0px||||false|false&#8221; custom_padding=&#8221;15px|15px|15px|15px|true|true&#8221; border_width_all=&#8221;1px&#8221; border_color_all=&#8221;#f3f3f3&#8243; global_colors_info=&#8221;{}&#8221;]<\/p>\n<h5 style=\"text-align: left;\">Eligibility and Reimbursement Appeal Form\uff08\u8d44\u683c\u548c\u62a5\u9500\u7533\u8bc9\u8868\uff09<\/h5>\n<p>\u4f7f\u7528\u6b64\u8868\u683c\uff0c\u586b\u5199\u89e3\u91ca\u60a8\u4e3a\u4ec0\u4e48\u8981\u6c42\u7533\u8bc9\u7684\u5b57\u6bb5\u6216\u8005\u4e0a\u4f20\u4e00\u5c01\u89e3\u91ca\u4fe1\u3002\u62a5\u9500\u7533\u8bc9\u5fc5\u987b\u9644\u6709\u652f\u6301\u6587\u6863\uff0c\u5982 Explanation of Benefits\uff08\u533b\u7597\u8d39\u5bf9\u8d26\u5355\uff0cEOB\uff09\u6216\u4ed8\u6b3e\u8bc1\u660e\u3002<\/p>\n<p><a class=\"noUnderline\" href=\"https:\/\/risepartnership.jotform.com\/212296895694070?language=zh\" target=\"_blank\" rel=\"noopener noreferrer\"><i class=\"fas fa-align-left\"><\/i><span style=\"text-decoration: underline;\">\u8bbf\u95ee\u8868\u683c<\/span><\/a><\/p>\n<p>[\/et_pb_text][et_pb_text _builder_version=&#8221;4.21.0&#8243; background_color=&#8221;#ffffff&#8221; max_width=&#8221;1000px&#8221; module_alignment=&#8221;center&#8221; height=&#8221;100%&#8221; custom_margin=&#8221;0px||||false|false&#8221; custom_padding=&#8221;15px|15px|15px|15px|true|true&#8221; border_width_all=&#8221;1px&#8221; border_color_all=&#8221;#f3f3f3&#8243; global_colors_info=&#8221;{}&#8221;]<\/p>\n<h5 style=\"text-align: left;\">VSP Member Reimbursement Form\uff08VSP \u4f1a\u5458\u62a5\u9500\u7533\u8bf7\u8868\uff09<\/h5>\n<p><span style=\"font-weight: 400;\">\u901a\u8fc7 VSP \u95e8\u6237\u7f51\u7ad9<a href=\"https:\/\/www.vsp.com\/\"> vsp.com<\/a> \u4ee5\u5728\u7ebf\u65b9\u5f0f\u7533\u8bf7\u62a5\u9500\u3002\u60a8\u9700\u8981\u5148\u521b\u5efa\u4e00\u4e2a\u8d26\u6237\u3002\u5982\u6709\u7591\u95ee\uff0c\u8bf7\u62d4\u6253 1-800-877-7195 \u8054\u7cfb VSP\u3002<\/span><\/p>\n<p>[\/et_pb_text][\/et_pb_column_inner][\/et_pb_row_inner][et_pb_row_inner module_id=&#8221;eapanchor&#8221; _builder_version=&#8221;4.16&#8243; custom_padding=&#8221;3px||2px|||&#8221; locked=&#8221;off&#8221; global_colors_info=&#8221;{}&#8221; collapsed=&#8221;on&#8221;][et_pb_column_inner saved_specialty_column_type=&#8221;3_4&#8243; _builder_version=&#8221;4.16&#8243; global_colors_info=&#8221;{}&#8221;][et_pb_text module_id=&#8221;eapanchor&#8221; _builder_version=&#8221;4.16&#8243; global_colors_info=&#8221;{}&#8221;]<\/p>\n<h2>\u5458\u5de5\u8f85\u52a9\u8ba1\u5212<\/h2>\n<p>[\/et_pb_text][\/et_pb_column_inner][\/et_pb_row_inner][et_pb_row_inner use_custom_gutter=&#8221;on&#8221; gutter_width=&#8221;1&#8243; custom_padding_last_edited=&#8221;on|phone&#8221; disabled_on=&#8221;off|off|off&#8221; module_class=&#8221;twoColumns&#8221; _builder_version=&#8221;4.16&#8243; background_enable_color=&#8221;off&#8221; custom_margin=&#8221;0px||25px||false|true&#8221; custom_padding=&#8221;0px|0px|0px|0px|false|true&#8221; custom_padding_tablet=&#8221;&#8221; custom_padding_phone=&#8221;0px|0px|0px|0px|false|true&#8221; border_radii=&#8221;on|0px|0px|0px|0px&#8221; locked=&#8221;off&#8221; global_colors_info=&#8221;{}&#8221; collapsed=&#8221;on&#8221;][et_pb_column_inner saved_specialty_column_type=&#8221;3_4&#8243; _builder_version=&#8221;4.16&#8243; background_enable_color=&#8221;off&#8221; global_colors_info=&#8221;{}&#8221;][et_pb_text disabled_on=&#8221;on|on|on&#8221; _builder_version=&#8221;4.23.1&#8243; background_color=&#8221;#ffffff&#8221; max_width=&#8221;1000px&#8221; module_alignment=&#8221;center&#8221; height=&#8221;100%&#8221; custom_margin=&#8221;0px||||false|false&#8221; custom_padding=&#8221;15px|15px|15px|15px|true|true&#8221; border_width_all=&#8221;1px&#8221; border_color_all=&#8221;#f3f3f3&#8243; disabled=&#8221;on&#8221; global_colors_info=&#8221;{}&#8221;]<\/p>\n<h5 style=\"text-align: left;\">Benefits Waiver Form\uff08\u798f\u5229\u5f03\u6743\u4e66\uff09<\/h5>\n<p>\u4f7f\u7528\u6b64\u8868\u683c\u5373\u8868\u793a\u60a8\u627f\u8ba4\u5df2\u83b7\u5f97 Carewell SEIU 503 \u7259\u79d1\u3001\u89c6\u529b+\u542c\u529b\u548c\u5458\u5de5\u8f85\u52a9\u8ba1\u5212 (EAP) \u4fdd\u9669\uff0c<u>\u5e76\u62d2\u7edd\u6b64\u4fdd\u9669<\/u>\u3002<\/p>\n<p><a class=\"noUnderline\" href=\"https:\/\/risepartnership.jotform.com\/212285204692050?language=zh\" target=\"_blank\" rel=\"noopener noreferrer\"> <i class=\"fas fa-align-left\"><\/i> \u8bbf\u95ee\u8868\u683c<\/a>[\/et_pb_text][et_pb_text disabled_on=&#8221;off|off|off&#8221; _builder_version=&#8221;4.23.1&#8243; background_color=&#8221;#ffffff&#8221; max_width=&#8221;1000px&#8221; module_alignment=&#8221;center&#8221; height=&#8221;100%&#8221; custom_margin=&#8221;0px||||false|false&#8221; custom_padding=&#8221;15px|15px|15px|15px|true|true&#8221; border_width_all=&#8221;1px&#8221; border_color_all=&#8221;#f3f3f3&#8243; global_colors_info=&#8221;{}&#8221;]<\/p>\n<h5 style=\"text-align: left;\">Benefits Waiver Form\uff08\u798f\u5229\u5f03\u6743\u4e66\uff09<\/h5>\n<p>\u4f7f\u7528\u6b64\u8868\u683c\u5373\u8868\u793a\u60a8\u627f\u8ba4\u5df2\u83b7\u5f97 Carewell SEIU 503 \u7259\u79d1\u3001\u89c6\u529b+\u542c\u529b\u548c\u5458\u5de5\u8f85\u52a9\u8ba1\u5212 (EAP) \u4fdd\u9669\uff0c<u>\u5e76\u62d2\u7edd\u6b64\u4fdd\u9669<\/u>\u3002<br \/>\n[et_pb_section global_module=\"274298\"][\/et_pb_section][\/et_pb_text][et_pb_text _builder_version=&#8221;4.27.4&#8243; text_line_height=&#8221;1.5em&#8221; background_color=&#8221;#ffffff&#8221; max_width=&#8221;1000px&#8221; module_alignment=&#8221;center&#8221; height=&#8221;100%&#8221; custom_margin=&#8221;0px||||false|false&#8221; custom_padding=&#8221;15px|15px|15px|15px|true|true&#8221; border_width_all=&#8221;1px&#8221; border_color_all=&#8221;#f3f3f3&#8243; global_colors_info=&#8221;{}&#8221;]<\/p>\n<h5 style=\"text-align: left;\">Eligibility and Reimbursement Appeal Form\uff08\u8d44\u683c\u548c\u62a5\u9500\u7533\u8bc9\u8868\uff09<\/h5>\n<p>\u4f7f\u7528\u6b64\u8868\u683c\uff0c\u586b\u5199\u89e3\u91ca\u60a8\u4e3a\u4ec0\u4e48\u8981\u6c42\u7533\u8bc9\u7684\u5b57\u6bb5\u6216\u8005\u4e0a\u4f20\u4e00\u5c01\u89e3\u91ca\u4fe1\u3002\u62a5\u9500\u7533\u8bc9\u5fc5\u987b\u9644\u6709\u652f\u6301\u6587\u6863\uff0c\u5982 Explanation of Benefits\uff08\u533b\u7597\u8d39\u5bf9\u8d26\u5355\uff0cEOB\uff09\u6216\u4ed8\u6b3e\u8bc1\u660e\u3002<\/p>\n<p><a class=\"noUnderline\" href=\"https:\/\/risepartnership.jotform.com\/212296895694070?language=zh\" target=\"_blank\" rel=\"noopener noreferrer\"><i class=\"fas fa-align-left\"><\/i><span style=\"text-decoration: underline;\">\u8bbf\u95ee\u8868\u683c<\/span><\/a><\/p>\n<p>[\/et_pb_text][\/et_pb_column_inner][\/et_pb_row_inner][et_pb_row_inner module_id=&#8221;hcaanchor&#8221; _builder_version=&#8221;4.16&#8243; custom_padding=&#8221;3px||2px|||&#8221; global_colors_info=&#8221;{}&#8221; collapsed=&#8221;on&#8221;][et_pb_column_inner saved_specialty_column_type=&#8221;3_4&#8243; _builder_version=&#8221;4.16&#8243; global_colors_info=&#8221;{}&#8221;][et_pb_text module_id=&#8221;hcaapanchor&#8221; _builder_version=&#8221;4.16&#8243; global_colors_info=&#8221;{}&#8221;]<\/p>\n<h2>\u533b\u7597\u4fdd\u5065\u8d39\u7528\u63f4\u52a9<\/h2>\n<h3>\u9488\u5bf9\u5df2\u6279\u51c6\u8ba1\u5212<\/h3>\n<p>[\/et_pb_text][\/et_pb_column_inner][\/et_pb_row_inner][et_pb_row_inner use_custom_gutter=&#8221;on&#8221; gutter_width=&#8221;1&#8243; _builder_version=&#8221;4.16&#8243; custom_margin=&#8221;0px||0px||false|false&#8221; custom_padding=&#8221;0px||0px||true|false&#8221; global_colors_info=&#8221;{}&#8221;][et_pb_column_inner saved_specialty_column_type=&#8221;3_4&#8243; _builder_version=&#8221;4.16&#8243; global_colors_info=&#8221;{}&#8221;][et_pb_text disabled_on=&#8221;off|off|off&#8221; _builder_version=&#8221;4.27.4&#8243; text_line_height=&#8221;1.5em&#8221; background_color=&#8221;#ffffff&#8221; max_width=&#8221;1000px&#8221; module_alignment=&#8221;center&#8221; height=&#8221;100%&#8221; custom_margin=&#8221;0px||||false|false&#8221; custom_padding=&#8221;15px|15px|15px|15px|true|true&#8221; hover_enabled=&#8221;0&#8243; border_width_all=&#8221;1px&#8221; border_color_all=&#8221;#f3f3f3&#8243; locked=&#8221;off&#8221; global_colors_info=&#8221;{}&#8221; sticky_enabled=&#8221;0&#8243;]<\/p>\n<h5 style=\"text-align: left;\">2026 \u5e74\u5ea6\u6587\u4ef6<\/h5>\n<p>\u586b\u5199\u5e74\u5ea6\u6587\u4ef6\u5373\u786e\u8ba4\u60a8\u7406\u89e3\u5e76\u540c\u610f\u7531\u4fe1\u6258\u89c4\u5b9a\u7ba1\u7406\u7684\u8ba1\u5212\u89c4\u5b9a\u3002\u8fd9\u4e9b\u8868\u683c\u8fd8\u6388\u6743 Carewell SEIU 503 Benefits \u56e2\u961f\u534f\u52a9\u60a8\u6ce8\u518c\u548c\u7ef4\u62a4\u60a8\u7684\u533b\u7597\u5065\u5eb7\u4fdd\u9669\u3002<strong>\u6b64\u6587\u4ef6\u5e76\u975e\u7528\u6765\u7533\u8bf7\u533b\u7597\u4fdd\u9669\u3002<\/strong><\/p>\n<p><a class=\"noUnderline\" href=\"https:\/\/risepartnership.jotform.com\/251466827408969?language=zh\" target=\"_blank\" rel=\"noopener noreferrer\"><i class=\"fas fa-align-left\"><\/i>\u8bbf\u95ee\u8868\u683c<\/a><\/p>\n<p>[\/et_pb_text][et_pb_text _builder_version=&#8221;4.27.4&#8243; text_line_height=&#8221;1.5em&#8221; background_color=&#8221;#ffffff&#8221; max_width=&#8221;1000px&#8221; module_alignment=&#8221;center&#8221; height=&#8221;100%&#8221; custom_margin=&#8221;0px||||false|false&#8221; custom_padding=&#8221;15px|15px|15px|15px|true|true&#8221; hover_enabled=&#8221;0&#8243; border_width_all=&#8221;1px&#8221; border_color_all=&#8221;#f3f3f3&#8243; locked=&#8221;off&#8221; global_colors_info=&#8221;{}&#8221; sticky_enabled=&#8221;0&#8243;]<\/p>\n<h5><strong>Healthcare Cost Assistance Benefits Request Form\uff08\u533b\u7597\u4fdd\u5065\u8d39\u7528\u63f4\u52a9\u798f\u5229\u7533\u8bf7\u8868\uff09<\/strong><\/h5>\n<p>\u586b\u5199\u6b64\u8868\u683c\u4ee5\u7533\u8bf7\u533b\u7597\u4fdd\u5065\u8d39\u7528\u63f4\u52a9\u798f\u5229\u3002\u60a8\u5fc5\u987b\u63d0\u4f9b Marketplace Eligibility Notice\uff08\u533b\u7597\u4fdd\u9669\u5e02\u573a\u8d44\u683c\u901a\u77e5\uff09\u548c\u60a8\u7684\u4fdd\u8d39\u8d26\u5355\u6216 <span><a href=\"https:\/\/www.healthcare.gov\/\">HealthCare.gov<\/a> \u5e10\u6237<\/span>\u4e2d\u7684 My Plans and Programs\uff08\u6211\u7684\u8ba1\u5212\uff09\u9875\u9762\uff0c\u8fd9\u6837\u624d\u6709\u8d44\u683c\u83b7\u5f97\u6b64\u798f\u5229\u3002\u5982\u679c\u60a8\u901a\u8fc7 Valley Insurance Professionals \u53c2\u52a0\u4e86\u5df2\u6279\u51c6\u8ba1\u5212\uff0c\u90a3\u4e48\u60a8\u65e0\u9700\u63d0\u4ea4\u6b64\u8868\u683c\u3002<\/p>\n<p><a class=\"noUnderline\" href=\"https:\/\/risepartnership.jotform.com\/231867527905163?language=zh\" target=\"_blank\" rel=\"noopener noreferrer\"> <i class=\"fas fa-align-left\"><\/i> <span style=\"text-decoration: underline;\">\u8bbf\u95ee\u8868\u683c<\/span><\/a><\/p>\n<p>[\/et_pb_text][et_pb_text disabled_on=&#8221;on|on|on&#8221; _builder_version=&#8221;4.27.4&#8243; text_line_height=&#8221;1.5em&#8221; background_color=&#8221;#ffffff&#8221; max_width=&#8221;1000px&#8221; module_alignment=&#8221;center&#8221; height=&#8221;100%&#8221; custom_margin=&#8221;0px||||false|false&#8221; custom_padding=&#8221;15px|15px|15px|15px|true|true&#8221; border_width_all=&#8221;1px&#8221; border_color_all=&#8221;#f3f3f3&#8243; disabled=&#8221;on&#8221; locked=&#8221;off&#8221; global_colors_info=&#8221;{}&#8221;]<\/p>\n<h5 style=\"text-align: left;\">HIPAA Authorization\uff08HIPAA \u6388\u6743\u4e66\uff09<\/h5>\n<p>\u672c\u901a\u77e5\u544a\u77e5\u60a8 Carewell SEIU 503 \u53ef\u80fd\u4f1a\u5982\u4f55\u4f7f\u7528\u548c\u5171\u4eab\u60a8\u7684\u5065\u5eb7\u4fe1\u606f\u3002\u5176\u4e2d\u8fd8\u5305\u62ec\u6709\u5173\u60a8\u7684\u5065\u5eb7\u9690\u79c1\u6743\u7684\u4fe1\u606f\u3002<\/p>\n<p><a class=\"noUnderline\" href=\"https:\/\/risepartnership.jotform.com\/212707140010032?language=zh\" target=\"_blank\" rel=\"noopener noreferrer\"> <i class=\"fas fa-align-left\"><\/i> <span style=\"text-decoration: underline;\">\u8bbf\u95ee\u8868\u683c<\/span><\/a><\/p>\n<p>[\/et_pb_text][et_pb_text disabled_on=&#8221;on|on|on&#8221; _builder_version=&#8221;4.27.4&#8243; text_line_height=&#8221;1.5em&#8221; background_color=&#8221;#ffffff&#8221; max_width=&#8221;1000px&#8221; module_alignment=&#8221;center&#8221; height=&#8221;100%&#8221; custom_margin=&#8221;0px||||false|false&#8221; custom_padding=&#8221;15px|15px|15px|15px|true|true&#8221; border_width_all=&#8221;1px&#8221; border_color_all=&#8221;#f3f3f3&#8243; disabled=&#8221;on&#8221; locked=&#8221;off&#8221; global_colors_info=&#8221;{}&#8221;]<\/p>\n<h5 style=\"text-align: left;\">\u7406\u89e3\u58f0\u660e<\/h5>\n<p>\u672c\u901a\u77e5\u65e8\u5728\u8ba9\u62a4\u7406\u670d\u52a1\u63d0\u4f9b\u8005\u660e\u767d\u4ed6\u4eec\u5728\u83b7\u5f97 Carewell SEIU 503 \u798f\u5229\u65b9\u9762\u7684\u8d23\u4efb\u3002<\/p>\n<p><a class=\"noUnderline\" href=\"https:\/\/risepartnership.jotform.com\/212707835282054?language=zh\" target=\"_blank\" rel=\"noopener\"> <i class=\"fas fa-align-left\"><\/i> <span style=\"text-decoration: underline;\">\u8bbf\u95ee\u8868\u683c<\/span><\/a><\/p>\n<p>[\/et_pb_text][\/et_pb_column_inner][\/et_pb_row_inner][et_pb_row_inner use_custom_gutter=&#8221;on&#8221; gutter_width=&#8221;1&#8243; _builder_version=&#8221;4.16&#8243; custom_margin=&#8221;0px||0px||false|false&#8221; custom_padding=&#8221;0px||0px||true|false&#8221; global_colors_info=&#8221;{}&#8221; collapsed=&#8221;on&#8221;][et_pb_column_inner saved_specialty_column_type=&#8221;3_4&#8243; _builder_version=&#8221;4.16&#8243; global_colors_info=&#8221;{}&#8221;][et_pb_text _builder_version=&#8221;4.27.4&#8243; text_line_height=&#8221;1.5em&#8221; background_color=&#8221;#ffffff&#8221; max_width=&#8221;1000px&#8221; module_alignment=&#8221;center&#8221; height=&#8221;100%&#8221; custom_margin=&#8221;0px||||false|false&#8221; custom_padding=&#8221;15px|15px|15px|15px|true|true&#8221; border_width_all=&#8221;1px&#8221; border_color_all=&#8221;#f3f3f3&#8243; global_colors_info=&#8221;{}&#8221;]<\/p>\n<h5 style=\"text-align: left;\">Consent to Release Information Form\uff08\u4fe1\u606f\u62ab\u9732\u540c\u610f\u4e66\uff09<\/h5>\n<p>\u5982\u679c\u60a8\u9700\u8981\u5141\u8bb8\u53d7\u4fe1\u4efb\u7684\u5bb6\u5ead\u6210\u5458\u6216\u670b\u53cb\u4ee3\u8868\u60a8\u8fdb\u884c\u54a8\u8be2\u3001\u5b89\u6392\u9884\u7ea6\u6216\u786e\u8ba4\u4fe1\u606f\uff0c\u8bf7\u586b\u5199\u6b64\u8868\u3002<\/p>\n<p><a class=\"noUnderline\" href=\"https:\/\/risepartnership.jotform.com\/212285476973063?language=zh\" target=\"_blank\" rel=\"noopener\"> <i class=\"fas fa-align-left\"><\/i> <span style=\"text-decoration: underline;\">\u8bbf\u95ee\u8868\u683c<\/span><\/a><\/p>\n<p>[\/et_pb_text][et_pb_text disabled_on=&#8221;on|on|on&#8221; _builder_version=&#8221;4.27.4&#8243; text_line_height=&#8221;1.5em&#8221; background_color=&#8221;#ffffff&#8221; max_width=&#8221;1000px&#8221; module_alignment=&#8221;center&#8221; height=&#8221;100%&#8221; custom_margin=&#8221;0px||||false|false&#8221; custom_padding=&#8221;15px|15px|15px|15px|true|true&#8221; border_width_all=&#8221;1px&#8221; border_color_all=&#8221;#f3f3f3&#8243; disabled=&#8221;on&#8221; locked=&#8221;off&#8221; global_colors_info=&#8221;{}&#8221;]<\/p>\n<h5 style=\"text-align: left;\">Valley Insurance Professionals (VIP) Agent of Record Form\uff08\u8bb0\u5f55\u4ee3\u7406\u8868\uff09<\/h5>\n<p>\u586b\u5199\u6b64\u8868\u683c\u4ee5\u6307\u5b9a VIP \u4f5c\u4e3a\u60a8\u7684\u8bb0\u5f55\u4ee3\u7406\uff0c\u4ee3\u8868\u5e76\u5e2e\u52a9\u60a8\u7ba1\u7406\u60a8\u7684\u4fdd\u9669\u5355\u3002<\/p>\n<p><a class=\"noUnderline\" href=\"https:\/\/risepartnership.jotform.com\/212707338765058?language=zh\" target=\"_blank\" rel=\"noopener\"> <i class=\"fas fa-align-left\"><\/i> <span style=\"text-decoration: underline;\">\u8bbf\u95ee\u8868\u683c<\/span><\/a><\/p>\n<p>[\/et_pb_text][\/et_pb_column_inner][\/et_pb_row_inner][et_pb_row_inner use_custom_gutter=&#8221;on&#8221; gutter_width=&#8221;1&#8243; _builder_version=&#8221;4.16&#8243; custom_margin=&#8221;0px||0px||false|false&#8221; custom_padding=&#8221;0px||0px||true|false&#8221; global_colors_info=&#8221;{}&#8221; collapsed=&#8221;on&#8221;][et_pb_column_inner saved_specialty_column_type=&#8221;3_4&#8243; _builder_version=&#8221;4.16&#8243; global_colors_info=&#8221;{}&#8221;][et_pb_text disabled_on=&#8221;on|on|on&#8221; _builder_version=&#8221;4.23.1&#8243; text_line_height=&#8221;1.5em&#8221; background_color=&#8221;#ffffff&#8221; max_width=&#8221;1000px&#8221; module_alignment=&#8221;center&#8221; height=&#8221;100%&#8221; custom_margin=&#8221;0px||||false|false&#8221; custom_padding=&#8221;15px|15px|15px|15px|true|true&#8221; border_width_all=&#8221;1px&#8221; border_color_all=&#8221;#f3f3f3&#8243; disabled=&#8221;on&#8221; global_colors_info=&#8221;{}&#8221;]<\/p>\n<h5 style=\"text-align: left;\">Direct Deposit Form\uff08\u76f4\u63a5\u5b58\u6b3e\u8868\uff09<\/h5>\n<p>\u6ce8\u518c\u5373\u53ef\u901a\u8fc7\u76f4\u63a5\u5b58\u6b3e\u83b7\u5f97\u4fdd\u9669\u8d39\u62a5\u9500\u3002\u8fd9\u662f\u6536\u5230\u4ed8\u6b3e\u7684\u6700\u5feb\u3001\u6700\u5b89\u5168\u7684\u65b9\u5f0f\u3002<strong>\u60a8\u5fc5\u987b\u9644\u4e0a\u4f5c\u5e9f\u652f\u7968\u3001\u94f6\u884c\u4fe1\u51fd\u6216\u94f6\u884c\u5bf9\u94f6\u884c\u7ed3\u5355\u7684\u526f\u672c\u3002<\/strong><\/p>\n<p><a class=\"noUnderline\" href=\"https:\/\/risepartnership.jotform.com\/212278209348964?language=zh\" target=\"_blank\" rel=\"noopener noreferrer\"> <i class=\"fas fa-align-left\"><\/i> \u8bbf\u95ee\u8868\u683c<\/a>[\/et_pb_text][et_pb_text disabled_on=&#8221;off|off|off&#8221; 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_builder_version=&#8221;4.23.1&#8243; text_line_height=&#8221;1.5em&#8221; background_color=&#8221;#ffffff&#8221; max_width=&#8221;1000px&#8221; module_alignment=&#8221;center&#8221; height=&#8221;100%&#8221; custom_margin=&#8221;0px||||false|false&#8221; custom_padding=&#8221;15px|15px|15px|15px|true|true&#8221; border_width_all=&#8221;1px&#8221; border_color_all=&#8221;#f3f3f3&#8243; locked=&#8221;off&#8221; global_colors_info=&#8221;{}&#8221;]<\/p>\n<h5 style=\"text-align: left;\">Medical Premium Reimbursement Claim Form\uff08\u533b\u7597\u4fdd\u9669\u8d39\u62a5\u9500\u7d22\u8d54\u7533\u8bf7\u8868\uff09<\/h5>\n<p>\u5982\u679c\u60a8\u7684\u5bb6\u5ead\u6210\u5458\u4e5f\u52a0\u5165\u4e86\u60a8\u7684\u4fdd\u9669\u8ba1\u5212\u548c\/\u6216\u60a8\u6709\u8d44\u683c\u83b7\u5f97\u67d0\u4e2a\u5c1a\u672a\u6279\u51c6\u7684\u8ba1\u5212\u7684\u4e34\u65f6\u5e73\u5747\u4fdd\u8d39\u62a5\u9500 (APR)\uff0c\u8bf7\u4f7f\u7528\u6b64\u8868\u683c\u6765\u62a5\u9500\u4fdd\u9669\u8d39\u3002\u63d0\u4ea4\u65f6\u5fc5\u987b\u9644\u4e0a\u4e2a\u4eba\u4fdd\u9669\u8bc1\u660e\u3002<br \/>\n[et_pb_section global_module=\"274303\"][\/et_pb_section][\/et_pb_text][\/et_pb_column_inner][\/et_pb_row_inner][et_pb_row_inner use_custom_gutter=&#8221;on&#8221; gutter_width=&#8221;1&#8243; custom_padding_last_edited=&#8221;on|phone&#8221; disabled_on=&#8221;off|off|off&#8221; module_class=&#8221;twoColumns&#8221; _builder_version=&#8221;4.16&#8243; background_enable_color=&#8221;off&#8221; custom_margin=&#8221;0px||25px||false|true&#8221; custom_padding=&#8221;0px|0px|0px|0px|false|true&#8221; custom_padding_tablet=&#8221;&#8221; custom_padding_phone=&#8221;0px|0px|0px|0px|false|true&#8221; border_radii=&#8221;on|0px|0px|0px|0px&#8221; global_colors_info=&#8221;{}&#8221;][et_pb_column_inner saved_specialty_column_type=&#8221;3_4&#8243; _builder_version=&#8221;4.16&#8243; background_enable_color=&#8221;off&#8221; global_colors_info=&#8221;{}&#8221;][et_pb_text disabled_on=&#8221;on|on|on&#8221; _builder_version=&#8221;4.27.4&#8243; background_color=&#8221;#ffffff&#8221; max_width=&#8221;1000px&#8221; module_alignment=&#8221;center&#8221; height=&#8221;100%&#8221; custom_margin=&#8221;0px||||false|false&#8221; custom_padding=&#8221;15px|15px|15px|15px|true|true&#8221; border_width_all=&#8221;1px&#8221; border_color_all=&#8221;#f3f3f3&#8243; disabled=&#8221;on&#8221; locked=&#8221;off&#8221; global_colors_info=&#8221;{}&#8221;]<\/p>\n<h5 style=\"text-align: left;\">Ameriflex Reimbursement Claim Form\uff08Ameriflex \u62a5\u9500\u7d22\u8d54\u7533\u8bf7\u8868\uff09<\/h5>\n<p class=\"p1\">\u5f53\u60a8\u7528\u81ea\u5df1\u7684\u8d44\u91d1\u800c\u4e0d\u662f\u4f7f\u7528 Benefit Convenience Card\uff08\u798f\u5229\u4fbf\u5229\u5361\uff09\u652f\u4ed8\u4e86\u627f\u4fdd\u8d39\u7528\u65f6\uff0c\u8bf7\u4f7f\u7528\u6b64\u8868\u683c\u7533\u8bf7\u62a5\u9500\u3002\u5982\u679c\u60a8\u9700\u8981\u62a5\u9500\u901a\u8fc7\u533b\u7597\u4fdd\u9669\u5e02\u573a\u8d2d\u4e70\u7684\u7ecf Carewell \u6279\u51c6\u7684\u4e2a\u4eba\u8ba1\u5212\u7684\u6bcf\u6708\u51c0\u4fdd\u8d39\uff0c\u4e5f\u53ef\u4ee5\u4f7f\u7528\u6b64\u8868\u3002\u00a0<\/p>\n<p><a class=\"noUnderline\" href=\"https:\/\/participant.myameriflex.com\/#\/login?returnUrl=https%253A%252F%252Fparticipant.myameriflex.com%252F\" target=\"_blank\" rel=\"noopener noreferrer\"> <i class=\"fas fa-align-left\"><\/i> <span style=\"text-decoration: underline;\">\u8bbf\u95ee\u8868\u683c<\/span><\/a><\/p>\n<p>[\/et_pb_text][et_pb_text disabled_on=&#8221;on|on|on&#8221; 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You can also use this form if you need to claim reimbursement for your net monthly premium for a Carewell-approved individual plan purchased through a health insurance Marketplace. Please follow the instructions once you have logged in to the Ameriflex website.[divi_library_shortcode id=\"294390\"]<\/p>\n\n\n-->[\/et_pb_text][et_pb_code _builder_version=&#8221;4.27.4&#8243; _module_preset=&#8221;default&#8221; custom_padding=&#8221;0px||0px||false|false&#8221; global_colors_info=&#8221;{}&#8221;][et_pb_section global_module=\"294390\"][\/et_pb_section][\/et_pb_code][et_pb_text disabled_on=&#8221;on|on|on&#8221; _builder_version=&#8221;4.23.1&#8243; text_line_height=&#8221;1.5em&#8221; background_color=&#8221;#ffffff&#8221; max_width=&#8221;1000px&#8221; module_alignment=&#8221;center&#8221; height=&#8221;100%&#8221; custom_margin=&#8221;0px||||false|false&#8221; custom_padding=&#8221;15px|15px|15px|15px|true|true&#8221; border_width_all=&#8221;1px&#8221; border_color_all=&#8221;#f3f3f3&#8243; disabled=&#8221;on&#8221; locked=&#8221;off&#8221; global_colors_info=&#8221;{}&#8221;]<\/p>\n<h5 style=\"text-align: left;\">Advance Premium Tax Credit Adjustment Form\uff08\u9884\u4ed8\u4fdd\u8d39\u7a0e\u6536\u62b5\u514d\u989d\u8c03\u6574\u8868\uff09<\/h5>\n<p>\u5982\u679c\u60a8\u7684\u6536\u5165\u4e0e\u60a8\u5728\u533b\u7597\u4fdd\u9669\u5e02\u573a\u7533\u8bf7\u4e2d\u5411 IRS \u62a5\u544a\u7684\u6536\u5165\u4e0d\u540c\uff0c\u8bf7\u4f7f\u7528\u6b64\u8868\u683c\u3002\u6211\u4eec\u5c06\u4f7f\u7528\u6b64\u8868\u683c\u6765\u5e2e\u52a9\u6211\u4eec\u786e\u5b9a\u662f\u5426\u53ef\u4ee5\u5e2e\u52a9\u60a8\u652f\u4ed8\u60a8\u5c1a\u672a\u652f\u4ed8\u7684\u91d1\u989d\uff0c\u6216\u8005\u60a8\u662f\u5426\u6536\u5230\u4e86\u7a0e\u6536\u62b5\u514d\u989d\u591a\u4ed8\u6b3e\u9879\u3002\u63d0\u4ea4\u65f6\u5fc5\u987b\u9644\u4e0a\u652f\u6301\u7684\u7a0e\u52a1\u6587\u4ef6\u3002<\/p>\n<p><a class=\"noUnderline\" href=\"https:\/\/risepartnership.jotform.com\/212297282699066?language=zh\" target=\"_blank\" rel=\"noopener noreferrer\"> <i class=\"fas fa-align-left\"><\/i> \u8bbf\u95ee\u8868\u683c<\/a>[\/et_pb_text][et_pb_text disabled_on=&#8221;off|off|off&#8221; _builder_version=&#8221;4.23.1&#8243; text_line_height=&#8221;1.5em&#8221; background_color=&#8221;#ffffff&#8221; max_width=&#8221;1000px&#8221; module_alignment=&#8221;center&#8221; height=&#8221;100%&#8221; custom_margin=&#8221;0px||||false|false&#8221; custom_padding=&#8221;15px|15px|15px|15px|true|true&#8221; border_width_all=&#8221;1px&#8221; border_color_all=&#8221;#f3f3f3&#8243; locked=&#8221;off&#8221; global_colors_info=&#8221;{}&#8221;]<\/p>\n<h5 style=\"text-align: left;\">Advance Premium Tax Credit Adjustment Form\uff08\u9884\u4ed8\u4fdd\u8d39\u7a0e\u6536\u62b5\u514d\u989d\u8c03\u6574\u8868\uff09<\/h5>\n<p>\u5982\u679c\u60a8\u7684\u6536\u5165\u4e0e\u60a8\u5728\u533b\u7597\u4fdd\u9669\u5e02\u573a\u7533\u8bf7\u4e2d\u5411 IRS \u62a5\u544a\u7684\u6536\u5165\u4e0d\u540c\uff0c\u8bf7\u4f7f\u7528\u6b64\u8868\u683c\u3002\u6211\u4eec\u5c06\u4f7f\u7528\u6b64\u8868\u683c\u6765\u5e2e\u52a9\u6211\u4eec\u786e\u5b9a\u662f\u5426\u53ef\u4ee5\u5e2e\u52a9\u60a8\u652f\u4ed8\u60a8\u5c1a\u672a\u652f\u4ed8\u7684\u91d1\u989d\uff0c\u6216\u8005\u60a8\u662f\u5426\u6536\u5230\u4e86\u7a0e\u6536\u62b5\u514d\u989d\u591a\u4ed8\u6b3e\u9879\u3002\u63d0\u4ea4\u65f6\u5fc5\u987b\u9644\u4e0a\u652f\u6301\u7684\u7a0e\u52a1\u6587\u4ef6\u3002<br \/>\n[et_pb_section global_module=\"274304\"][\/et_pb_section][\/et_pb_text][et_pb_text _builder_version=&#8221;4.27.4&#8243; text_line_height=&#8221;1.5em&#8221; background_color=&#8221;#ffffff&#8221; max_width=&#8221;1000px&#8221; module_alignment=&#8221;center&#8221; height=&#8221;100%&#8221; custom_margin=&#8221;0px||||false|false&#8221; custom_padding=&#8221;15px|15px|15px|15px|true|true&#8221; border_width_all=&#8221;1px&#8221; border_color_all=&#8221;#f3f3f3&#8243; locked=&#8221;off&#8221; global_colors_info=&#8221;{}&#8221;]<\/p>\n<h5 style=\"text-align: left;\">Eligibility and Reimbursement Appeal Form\uff08\u8d44\u683c\u548c\u62a5\u9500\u7533\u8bc9\u8868\uff09<\/h5>\n<p>\u4f7f\u7528\u6b64\u8868\u683c\uff0c\u586b\u5199\u89e3\u91ca\u60a8\u4e3a\u4ec0\u4e48\u8981\u6c42\u7533\u8bc9\u7684\u5b57\u6bb5\u6216\u8005\u4e0a\u4f20\u4e00\u5c01\u89e3\u91ca\u4fe1\u3002\u62a5\u9500\u7533\u8bc9\u5fc5\u987b\u9644\u6709\u652f\u6301\u6587\u6863\uff0c\u5982 Explanation of Benefits\uff08\u533b\u7597\u8d39\u5bf9\u8d26\u5355\uff0cEOB\uff09\u6216\u4ed8\u6b3e\u8bc1\u660e\u3002<\/p>\n<p><a class=\"noUnderline\" href=\"https:\/\/risepartnership.jotform.com\/212296895694070?language=zh\" target=\"_blank\" rel=\"noopener noreferrer\"> <i class=\"fas fa-align-left\"><\/i> <span style=\"text-decoration: underline;\">\u8bbf\u95ee\u8868\u683c<\/span><\/a><\/p>\n<p>[\/et_pb_text][et_pb_text _builder_version=&#8221;4.27.4&#8243; _module_preset=&#8221;default&#8221; background_color=&#8221;#ffffff&#8221; custom_padding=&#8221;15px|15px|15px|15px|false|false&#8221; global_colors_info=&#8221;{}&#8221;]<\/p>\n<h5 style=\"text-align: left;\"><span style=\"color: #582c82;\">Overpayment Notice Appeal Form\uff08\u591a\u4ed8\u6b3e\u9879\u901a\u77e5\u7533\u8bc9\u8868\uff09<\/span><\/h5>\n<p>\u4f7f\u7528\u6b64\u8868\u683c\u5bf9 Carewell SEIU 503 \u7684\u591a\u4ed8\u6b3e\u9879\u901a\u77e5\u63d0\u51fa\u7533\u8bc9\u3002<\/p>\n<p><a class=\"noUnderline\" href=\"https:\/\/risepartnership.jotform.com\/241055798317059?language=zh\" target=\"_blank\" rel=\"noopener noreferrer\"><i class=\"fas fa-align-left\"><\/i><span style=\"text-decoration: underline;\">\u8bbf\u95ee\u8868\u683c<\/span><\/a><\/p>\n<p>[\/et_pb_text][\/et_pb_column_inner][\/et_pb_row_inner][et_pb_row_inner _builder_version=&#8221;4.16&#8243; custom_padding=&#8221;3px||2px|||&#8221; locked=&#8221;off&#8221; global_colors_info=&#8221;{}&#8221;][et_pb_column_inner saved_specialty_column_type=&#8221;3_4&#8243; _builder_version=&#8221;4.16&#8243; global_colors_info=&#8221;{}&#8221;][et_pb_text module_id=&#8221;hcamedicareanchor&#8221; _builder_version=&#8221;4.16&#8243; global_colors_info=&#8221;{}&#8221;]<\/p>\n<h2>\u533b\u7597\u4fdd\u5065\u8d39\u7528\u63f4\u52a9<\/h2>\n<h3>\u9488\u5bf9 Medicare \u8054\u90a6\u533b\u7597\u4fdd\u9669<\/h3>\n<p>[\/et_pb_text][\/et_pb_column_inner][\/et_pb_row_inner][et_pb_row_inner use_custom_gutter=&#8221;on&#8221; gutter_width=&#8221;1&#8243; _builder_version=&#8221;4.16&#8243; custom_margin=&#8221;0px||0px||false|false&#8221; custom_padding=&#8221;0px||0px||true|false&#8221; global_colors_info=&#8221;{}&#8221;][et_pb_column_inner saved_specialty_column_type=&#8221;3_4&#8243; _builder_version=&#8221;4.16&#8243; global_colors_info=&#8221;{}&#8221;][et_pb_text disabled_on=&#8221;off|off|off&#8221; _builder_version=&#8221;4.27.4&#8243; text_line_height=&#8221;1.5em&#8221; background_color=&#8221;#ffffff&#8221; max_width=&#8221;1000px&#8221; module_alignment=&#8221;center&#8221; height=&#8221;100%&#8221; custom_margin=&#8221;0px||||false|false&#8221; custom_padding=&#8221;15px|15px|15px|15px|true|true&#8221; border_width_all=&#8221;1px&#8221; border_color_all=&#8221;#f3f3f3&#8243; locked=&#8221;off&#8221; global_colors_info=&#8221;{}&#8221;]<\/p>\n<h5 style=\"text-align: left;\">Medicare \u8054\u90a6\u533b\u7597\u4fdd\u9669\u533b\u7597\u4fdd\u5065\u8d39\u7528\u63f4\u52a9\u798f\u5229\u7533\u8bf7\u8868<\/h5>\n<p data-pm-slice=\"1 1 []\">\u4f7f\u7528\u6b64\u8868\u63d0\u4ea4\u60a8\u6240\u9700\u7684\u6587\u4ef6\uff0c\u4ee5\u7533\u8bf7\u62a5\u9500\u90e8\u5206 Medicare \u8054\u90a6\u533b\u7597\u4fdd\u9669\u8d39\u5e76\u83b7\u5f97\u81ea\u4ed8\u533b\u7597\u8d39\u7528\u8d44\u91d1\u3002[et_pb_section global_module=\"274305\"][\/et_pb_section]<\/p>\n<p>[\/et_pb_text][et_pb_text disabled_on=&#8221;on|on|on&#8221; _builder_version=&#8221;4.27.4&#8243; background_color=&#8221;#ffffff&#8221; max_width=&#8221;1000px&#8221; module_alignment=&#8221;center&#8221; height=&#8221;100%&#8221; custom_margin=&#8221;0px||||false|false&#8221; custom_padding=&#8221;15px|15px|15px|15px|true|true&#8221; border_width_all=&#8221;1px&#8221; border_color_all=&#8221;#f3f3f3&#8243; disabled=&#8221;on&#8221; locked=&#8221;off&#8221; global_colors_info=&#8221;{}&#8221;]<\/p>\n<h5 style=\"text-align: left;\">Ameriflex Reimbursement Claim Form\uff08Ameriflex \u62a5\u9500\u7d22\u8d54\u7533\u8bf7\u8868\uff09<\/h5>\n<p class=\"p1\">\u5f53\u60a8\u7528\u81ea\u5df1\u7684\u8d44\u91d1\u800c\u4e0d\u662f\u4f7f\u7528 Benefit Convenience Card\uff08\u798f\u5229\u4fbf\u5229\u5361\uff09\u652f\u4ed8\u4e86\u627f\u4fdd\u8d39\u7528\u65f6\uff0c\u8bf7\u4f7f\u7528\u6b64\u8868\u683c\u7533\u8bf7\u62a5\u9500\u3002\u5982\u679c\u60a8\u9700\u8981\u62a5\u9500\u901a\u8fc7\u533b\u7597\u4fdd\u9669\u5e02\u573a\u8d2d\u4e70\u7684\u7ecf Carewell \u6279\u51c6\u7684\u4e2a\u4eba\u8ba1\u5212\u7684\u6bcf\u6708\u51c0\u4fdd\u8d39\uff0c\u4e5f\u53ef\u4ee5\u4f7f\u7528\u6b64\u8868\u3002\u00a0<\/p>\n<p><a class=\"noUnderline\" href=\"https:\/\/participant.myameriflex.com\/#\/login?returnUrl=https%253A%252F%252Fparticipant.myameriflex.com%252F\" target=\"_blank\" rel=\"noopener noreferrer\"> <i class=\"fas fa-align-left\"><\/i> <span style=\"text-decoration: underline;\">\u8bbf\u95ee\u8868\u683c<\/span><\/a><\/p>\n<p>[\/et_pb_text][et_pb_text disabled_on=&#8221;off|off|off&#8221; _builder_version=&#8221;4.27.4&#8243; background_color=&#8221;#ffffff&#8221; max_width=&#8221;1000px&#8221; module_alignment=&#8221;center&#8221; height=&#8221;100%&#8221; custom_margin=&#8221;0px||||false|false&#8221; custom_padding=&#8221;15px|15px|15px|15px|true|true&#8221; border_width_all=&#8221;1px&#8221; border_color_all=&#8221;#f3f3f3&#8243; locked=&#8221;off&#8221; global_colors_info=&#8221;{}&#8221;]<\/p>\n<p class=\"p1\">[et_pb_section global_module=\"294390\"][\/et_pb_section]<\/p>\n<p>[\/et_pb_text][et_pb_text disabled_on=&#8221;on|on|on&#8221; _builder_version=&#8221;4.23.1&#8243; text_line_height=&#8221;1.5em&#8221; background_color=&#8221;#ffffff&#8221; max_width=&#8221;1000px&#8221; module_alignment=&#8221;center&#8221; height=&#8221;100%&#8221; custom_margin=&#8221;0px||||false|false&#8221; custom_padding=&#8221;15px|15px|15px|15px|true|true&#8221; border_width_all=&#8221;1px&#8221; border_color_all=&#8221;#f3f3f3&#8243; disabled=&#8221;on&#8221; global_colors_info=&#8221;{}&#8221;]<\/p>\n<h5 style=\"text-align: left;\">Carewell Medicare Paperwork\uff08Carewell Medicare \u8054\u90a6\u533b\u7597\u4fdd\u9669\u6587\u4ef6\uff09<\/h5>\n<p>\u5f53\u60a8\u7b2c\u4e00\u6b21\u8fc7\u6e21\u5230 Medicare \u8054\u90a6\u533b\u7597\u4fdd\u9669\u65f6\uff0c\u8bf7\u586b\u5199\u8fd9\u4efd\u6587\u4ef6\uff0c\u4ee5\u4e86\u89e3\u60a8\u662f\u5426\u6709\u8d44\u683c\u83b7\u5f97\u533b\u7597\u4fdd\u5065\u8d39\u7528\u63f4\u52a9\u3002<span>\u586b\u5199\u6b64\u6587\u4ef6\u5373\u786e\u8ba4\u60a8\u7406\u89e3\u5e76\u540c\u610f\u7531\u4fe1\u6258\u89c4\u5b9a\u7ba1\u7406\u7684\u8ba1\u5212\u89c4\u5b9a\u3002<\/span>\u8bf7\u6ce8\u610f\uff1a\u5982\u679c\u8ba1\u5212\u53d1\u751f\u66f4\u6539\uff0c\u60a8\u8981\u518d\u6b21\u586b\u5199\u6b64\u6587\u4ef6\u3002<\/p>\n<p><a class=\"noUnderline\" href=\"https:\/\/risepartnership.jotform.com\/212365814640049?language=zh\" target=\"_blank\" rel=\"noopener noreferrer\"> <i class=\"fas fa-align-left\"><\/i> \u8bbf\u95ee\u8868\u683c<\/a>[\/et_pb_text][et_pb_text disabled_on=&#8221;off|off|off&#8221; _builder_version=&#8221;4.27.4&#8243; text_line_height=&#8221;1.5em&#8221; background_color=&#8221;#ffffff&#8221; max_width=&#8221;1000px&#8221; module_alignment=&#8221;center&#8221; height=&#8221;100%&#8221; custom_margin=&#8221;0px||||false|false&#8221; custom_padding=&#8221;15px|15px|15px|15px|true|true&#8221; border_width_all=&#8221;1px&#8221; border_color_all=&#8221;#f3f3f3&#8243; global_colors_info=&#8221;{}&#8221;]<\/p>\n<h5 style=\"text-align: left;\">Valley Insurance Professionals (VIP) Medicare \u8054\u90a6\u533b\u7597\u4fdd\u9669\u6587\u4ef6<\/h5>\n<p><span>\u8fd9\u4e9b\u8868\u683c\u7ed9\u4e88 Valley Insurance Professionals \u6cd5\u5f8b\u8bb8\u53ef\uff0c\u4ee5\u5e2e\u52a9\u60a8\u7814\u7a76\u3001\u6ce8\u518c\u548c\u7ef4\u6301\u60a8\u7684 Medicare \u8054\u90a6\u533b\u7597\u4fdd\u9669 Supplement\u3001Advantage \u6216 Part D \u8ba1\u5212\u3002<\/span><\/p>\n<p><a class=\"noUnderline\" href=\"https:\/\/risepartnership.jotform.com\/212365814640049?language=zh\" target=\"_blank\" rel=\"noopener noreferrer\"> <i class=\"fas fa-align-left\"><\/i><span style=\"text-decoration: underline;\">\u00a0\u8bbf\u95ee\u8868\u683c<\/span><\/a><\/p>\n<p>[\/et_pb_text][et_pb_text _builder_version=&#8221;4.27.4&#8243; text_line_height=&#8221;1.5em&#8221; background_color=&#8221;#ffffff&#8221; max_width=&#8221;1000px&#8221; module_alignment=&#8221;center&#8221; height=&#8221;100%&#8221; custom_margin=&#8221;0px||||false|false&#8221; custom_padding=&#8221;15px|15px|15px|15px|true|true&#8221; border_width_all=&#8221;1px&#8221; border_color_all=&#8221;#f3f3f3&#8243; global_colors_info=&#8221;{}&#8221;]<\/p>\n<h5 style=\"text-align: left;\">Consent to Release Information Form\uff08\u4fe1\u606f\u62ab\u9732\u540c\u610f\u4e66\uff09<\/h5>\n<p>\u5982\u679c\u60a8\u9700\u8981\u5141\u8bb8\u53d7\u4fe1\u4efb\u7684\u5bb6\u5ead\u6210\u5458\u6216\u670b\u53cb\u4ee3\u8868\u60a8\u8fdb\u884c\u54a8\u8be2\u3001\u5b89\u6392\u9884\u7ea6\u6216\u786e\u8ba4\u4fe1\u606f\uff0c\u8bf7\u586b\u5199\u6b64\u8868\u3002<\/p>\n<p><a class=\"noUnderline\" href=\"https:\/\/risepartnership.jotform.com\/212285476973063?language=zh\" target=\"_blank\" rel=\"noopener noreferrer\"> <i class=\"fas fa-align-left\"><\/i> <span style=\"text-decoration: underline;\">\u8bbf\u95ee\u8868\u683c<\/span><\/a><\/p>\n<p>[\/et_pb_text][et_pb_text disabled_on=&#8221;on|on|on&#8221; _builder_version=&#8221;4.23.1&#8243; text_line_height=&#8221;1.5em&#8221; background_color=&#8221;#ffffff&#8221; max_width=&#8221;1000px&#8221; module_alignment=&#8221;center&#8221; height=&#8221;100%&#8221; custom_margin=&#8221;0px||||false|false&#8221; custom_padding=&#8221;15px|15px|15px|15px|true|true&#8221; border_width_all=&#8221;1px&#8221; border_color_all=&#8221;#f3f3f3&#8243; disabled=&#8221;on&#8221; global_colors_info=&#8221;{}&#8221;]<\/p>\n<h5 style=\"text-align: left;\">Direct Deposit Form\uff08\u76f4\u63a5\u5b58\u6b3e\u8868\uff09<\/h5>\n<p>\u6ce8\u518c\u5373\u53ef\u901a\u8fc7\u76f4\u63a5\u5b58\u6b3e\u83b7\u5f97\u4fdd\u9669\u8d39\u62a5\u9500\u3002\u8fd9\u662f\u6536\u5230\u4ed8\u6b3e\u7684\u6700\u5feb\u3001\u6700\u5b89\u5168\u7684\u65b9\u5f0f\u3002<strong>\u60a8\u5fc5\u987b\u9644\u4e0a\u4f5c\u5e9f\u652f\u7968\u3001\u94f6\u884c\u4fe1\u51fd\u6216\u94f6\u884c\u5bf9\u94f6\u884c\u7ed3\u5355\u7684\u526f\u672c\u3002<\/strong><\/p>\n<p><a class=\"noUnderline\" href=\"https:\/\/risepartnership.jotform.com\/212278209348964?language=zh\" target=\"_blank\" rel=\"noopener noreferrer\"> <i class=\"fas fa-align-left\"><\/i> \u8bbf\u95ee\u8868\u683c<\/a>[\/et_pb_text][et_pb_text disabled_on=&#8221;off|off|off&#8221; _builder_version=&#8221;4.23.1&#8243; text_line_height=&#8221;1.5em&#8221; background_color=&#8221;#ffffff&#8221; max_width=&#8221;1000px&#8221; module_alignment=&#8221;center&#8221; height=&#8221;100%&#8221; custom_margin=&#8221;0px||||false|false&#8221; custom_padding=&#8221;15px|15px|15px|15px|true|true&#8221; border_width_all=&#8221;1px&#8221; border_color_all=&#8221;#f3f3f3&#8243; global_colors_info=&#8221;{}&#8221;]<\/p>\n<h5 style=\"text-align: left;\">Direct Deposit Form\uff08\u76f4\u63a5\u5b58\u6b3e\u8868\uff09<\/h5>\n<p>\u6ce8\u518c\u5373\u53ef\u901a\u8fc7\u76f4\u63a5\u5b58\u6b3e\u83b7\u5f97\u4fdd\u9669\u8d39\u62a5\u9500\u3002\u8fd9\u662f\u6536\u5230\u4ed8\u6b3e\u7684\u6700\u5feb\u3001\u6700\u5b89\u5168\u7684\u65b9\u5f0f\u3002<strong>\u60a8\u5fc5\u987b\u9644\u4e0a\u4f5c\u5e9f\u652f\u7968\u3001\u94f6\u884c\u4fe1\u51fd\u6216\u94f6\u884c\u5bf9\u94f6\u884c\u7ed3\u5355\u7684\u526f\u672c\u3002<\/strong><br \/>\n[et_pb_section global_module=\"274302\"][\/et_pb_section][\/et_pb_text][\/et_pb_column_inner][\/et_pb_row_inner][et_pb_row_inner use_custom_gutter=&#8221;on&#8221; gutter_width=&#8221;1&#8243; _builder_version=&#8221;4.16&#8243; custom_margin=&#8221;0px||0px||false|false&#8221; custom_padding=&#8221;0px||0px||true|false&#8221; global_colors_info=&#8221;{}&#8221;][et_pb_column_inner saved_specialty_column_type=&#8221;3_4&#8243; _builder_version=&#8221;4.16&#8243; global_colors_info=&#8221;{}&#8221;][et_pb_text disabled_on=&#8221;on|on|on&#8221; _builder_version=&#8221;4.23.1&#8243; text_line_height=&#8221;1.5em&#8221; background_color=&#8221;#ffffff&#8221; max_width=&#8221;1000px&#8221; module_alignment=&#8221;center&#8221; height=&#8221;100%&#8221; custom_margin=&#8221;0px||||false|false&#8221; custom_padding=&#8221;15px|15px|15px|15px|true|true&#8221; border_width_all=&#8221;1px&#8221; border_color_all=&#8221;#f3f3f3&#8243; disabled=&#8221;on&#8221; locked=&#8221;off&#8221; global_colors_info=&#8221;{}&#8221;]<\/p>\n<h5 style=\"text-align: left;\">Medicare Premium Reimbursement Claim Form\uff08Medicare \u8054\u90a6\u533b\u7597\u4fdd\u9669\u4fdd\u8d39\u62a5\u9500\u7d22\u8d54\u7533\u8bf7\u8868\uff09<\/h5>\n<p>\u4f7f\u7528\u6b64\u8868\u683c\u83b7\u5f97\u62a5\u9500\u7684 Medicare \u8054\u90a6\u533b\u7597\u4fdd\u9669\u8d39 \u2014 \u4f8b\u5982 Medicare \u8054\u90a6\u533b\u7597\u4fdd\u9669 Part B \u7684\u6708\u5ea6\u4fdd\u8d39\uff0cMedicare \u8054\u90a6\u533b\u7597\u4fdd\u9669 Part D\u3001Supplement \u548c Advantage \u8ba1\u5212\u7684\u6708\u5ea6\u4fdd\u8d39\u3002<br \/>\n[et_pb_section global_module=\"274305\"][\/et_pb_section][\/et_pb_text][\/et_pb_column_inner][\/et_pb_row_inner][et_pb_row_inner use_custom_gutter=&#8221;on&#8221; gutter_width=&#8221;1&#8243; _builder_version=&#8221;4.16&#8243; custom_margin=&#8221;0px||0px||false|false&#8221; custom_padding=&#8221;0px||0px||true|false&#8221; global_colors_info=&#8221;{}&#8221;][et_pb_column_inner saved_specialty_column_type=&#8221;3_4&#8243; _builder_version=&#8221;4.16&#8243; global_colors_info=&#8221;{}&#8221;][et_pb_text _builder_version=&#8221;4.27.4&#8243; text_line_height=&#8221;1.5em&#8221; background_color=&#8221;#ffffff&#8221; max_width=&#8221;1000px&#8221; module_alignment=&#8221;center&#8221; height=&#8221;100%&#8221; custom_margin=&#8221;0px||||false|false&#8221; custom_padding=&#8221;15px|15px|15px|15px|true|true&#8221; border_width_all=&#8221;1px&#8221; border_color_all=&#8221;#f3f3f3&#8243; locked=&#8221;off&#8221; global_colors_info=&#8221;{}&#8221;]<\/p>\n<h5 style=\"text-align: left;\">Eligibility and Reimbursement Appeal Form\uff08\u8d44\u683c\u548c\u62a5\u9500\u7533\u8bc9\u8868\uff09<\/h5>\n<p>\u4f7f\u7528\u6b64\u8868\u683c\uff0c\u586b\u5199\u89e3\u91ca\u60a8\u4e3a\u4ec0\u4e48\u8981\u6c42\u7533\u8bc9\u7684\u5b57\u6bb5\u6216\u8005\u4e0a\u4f20\u4e00\u5c01\u89e3\u91ca\u4fe1\u3002\u62a5\u9500\u7533\u8bc9\u5fc5\u987b\u9644\u6709\u652f\u6301\u6587\u6863\uff0c\u5982 Explanation of Benefits\uff08\u533b\u7597\u8d39\u5bf9\u8d26\u5355\uff0cEOB\uff09\u6216\u4ed8\u6b3e\u8bc1\u660e\u3002<\/p>\n<p><a class=\"noUnderline\" href=\"https:\/\/risepartnership.jotform.com\/212296895694070?language=zh\" target=\"_blank\" rel=\"noopener noreferrer\"> <i class=\"fas fa-align-left\"><\/i> <span style=\"text-decoration: underline;\">\u8bbf\u95ee\u8868\u683c<\/span><\/a><\/p>\n<p>[\/et_pb_text][et_pb_text _builder_version=&#8221;4.27.4&#8243; _module_preset=&#8221;default&#8221; background_color=&#8221;#ffffff&#8221; custom_padding=&#8221;15px|15px|15px|15px|false|false&#8221; global_colors_info=&#8221;{}&#8221;]<\/p>\n<h5 style=\"text-align: left;\"><span style=\"color: #582c82;\">Overpayment Notice Appeal Form\uff08\u591a\u4ed8\u6b3e\u9879\u901a\u77e5\u7533\u8bc9\u8868\uff09<\/span><\/h5>\n<p>\u4f7f\u7528\u6b64\u8868\u683c\u5bf9 Carewell SEIU 503 \u7684\u591a\u4ed8\u6b3e\u9879\u901a\u77e5\u63d0\u51fa\u7533\u8bc9\u3002<\/p>\n<p><a class=\"noUnderline\" href=\"https:\/\/risepartnership.jotform.com\/241055798317059?language=zh\" target=\"_blank\" rel=\"noopener noreferrer\"><i class=\"fas fa-align-left\"><\/i><span style=\"text-decoration: underline;\">\u8bbf\u95ee\u8868\u683c<\/span><\/a><\/p>\n<p>[\/et_pb_text][\/et_pb_column_inner][\/et_pb_row_inner][et_pb_row_inner _builder_version=&#8221;4.16&#8243; custom_margin=&#8221;15px||||false|false&#8221; custom_padding=&#8221;3px||2px||false|false&#8221; global_colors_info=&#8221;{}&#8221;][et_pb_column_inner saved_specialty_column_type=&#8221;3_4&#8243; _builder_version=&#8221;4.16&#8243; global_colors_info=&#8221;{}&#8221;][et_pb_text module_id=&#8221;ptoanchor&#8221; _builder_version=&#8221;4.16&#8243; global_colors_info=&#8221;{}&#8221;]<\/p>\n<h2>\u5e26\u85aa\u5047\u00a0<\/h2>\n<p>[\/et_pb_text][\/et_pb_column_inner][\/et_pb_row_inner][et_pb_row_inner use_custom_gutter=&#8221;on&#8221; gutter_width=&#8221;1&#8243; _builder_version=&#8221;4.16&#8243; custom_margin=&#8221;0px||0px||false|false&#8221; custom_padding=&#8221;0px||0px||true|false&#8221; global_colors_info=&#8221;{}&#8221;][et_pb_column_inner saved_specialty_column_type=&#8221;3_4&#8243; _builder_version=&#8221;4.16&#8243; global_colors_info=&#8221;{}&#8221;][et_pb_text disabled_on=&#8221;on|on|on&#8221; _builder_version=&#8221;4.23.1&#8243; background_color=&#8221;#ffffff&#8221; max_width=&#8221;1000px&#8221; module_alignment=&#8221;center&#8221; height=&#8221;100%&#8221; custom_margin=&#8221;0px||||false|false&#8221; custom_padding=&#8221;15px|15px|15px|15px|true|true&#8221; border_width_all=&#8221;1px&#8221; border_color_all=&#8221;#f3f3f3&#8243; disabled=&#8221;on&#8221; global_colors_info=&#8221;{}&#8221;]<\/p>\n<h5 style=\"text-align: left;\">PTO \u798f\u5229\u7533\u8bf7\u6587\u6863\u5305<\/h5>\n<p>\u5982\u679c\u60a8\u7d2f\u79ef\u7684 PTO \u8fbe\u5230 8 \u5c0f\u65f6\u6216\u66f4\u591a\uff0c\u8bf7\u4f7f\u7528\u6b64\u8868\u683c\u7533\u8bf7\u652f\u4ed8\u60a8\u7684 PTO \u798f\u5229\u3002<\/p>\n<p><a class=\"noUnderline\" href=\"https:\/\/www.carewellseiu503.org\/zh-hans\/mycarewell503\/\" target=\"_blank\" rel=\"noopener noreferrer\">\u901a\u8fc7 MyCarewell503 \u586b\u5199\u8868\u683c<\/a><\/p>\n<p>[\/et_pb_text][et_pb_text disabled_on=&#8221;off|off|off&#8221; _builder_version=&#8221;4.23.1&#8243; background_color=&#8221;#ffffff&#8221; max_width=&#8221;1000px&#8221; module_alignment=&#8221;center&#8221; height=&#8221;100%&#8221; custom_margin=&#8221;0px||||false|false&#8221; custom_padding=&#8221;15px|15px|15px|15px|true|true&#8221; border_width_all=&#8221;1px&#8221; border_color_all=&#8221;#f3f3f3&#8243; global_colors_info=&#8221;{}&#8221;]<\/p>\n<h5 style=\"text-align: left;\">PTO \u798f\u5229\u7533\u8bf7\u6587\u6863\u5305<\/h5>\n<p>\u5982\u679c\u60a8\u7d2f\u79ef\u7684 PTO \u8fbe\u5230 8 \u5c0f\u65f6\u6216\u66f4\u591a\uff0c\u8bf7\u4f7f\u7528\u6b64\u8868\u683c\u7533\u8bf7\u652f\u4ed8\u60a8\u7684 PTO \u798f\u5229\u3002<br \/>[et_pb_section global_module=\"274306\"][\/et_pb_section]<\/p>\n<p>[\/et_pb_text][et_pb_text disabled_on=&#8221;on|on|on&#8221; _builder_version=&#8221;4.23.1&#8243; background_color=&#8221;#ffffff&#8221; max_width=&#8221;1000px&#8221; module_alignment=&#8221;center&#8221; height=&#8221;100%&#8221; custom_margin=&#8221;0px||||false|false&#8221; custom_padding=&#8221;15px|15px|15px|15px|true|true&#8221; border_width_all=&#8221;1px&#8221; border_color_all=&#8221;#f3f3f3&#8243; disabled=&#8221;on&#8221; global_colors_info=&#8221;{}&#8221;]<\/p>\n<h5 style=\"text-align: left;\">PTO \u798f\u5229\u7533\u8bf7\u6587\u6863\u5305<\/h5>\n<p>\u5982\u679c\u60a8\u7d2f\u79ef\u7684 PTO \u8fbe\u5230 8 \u5c0f\u65f6\u6216\u66f4\u591a\uff0c\u8bf7\u4f7f\u7528\u6b64\u8868\u683c\u7533\u8bf7\u652f\u4ed8\u60a8\u7684 PTO \u798f\u5229\u3002<\/p>\n<p><a class=\"noUnderline\" href=\"https:\/\/risepartnership.jotform.com\/211335760790152?language=zh\" target=\"_blank\" rel=\"noopener noreferrer\"> <i class=\"fas fa-align-left\"><\/i> \u5728\u7ebf\u8868\u683c<\/a><\/p>\n<p>[\/et_pb_text][et_pb_text disabled_on=&#8221;on|on|on&#8221; _builder_version=&#8221;4.23.1&#8243; background_color=&#8221;#ffffff&#8221; max_width=&#8221;1000px&#8221; module_alignment=&#8221;center&#8221; height=&#8221;100%&#8221; custom_margin=&#8221;0px||||false|false&#8221; custom_padding=&#8221;15px|15px|15px|15px|true|true&#8221; border_width_all=&#8221;1px&#8221; border_color_all=&#8221;#f3f3f3&#8243; disabled=&#8221;on&#8221; locked=&#8221;off&#8221; global_colors_info=&#8221;{}&#8221;]<\/p>\n<h5 style=\"text-align: left;\">Form W-9\uff08W-9 \u8868\u683c\uff09<\/h5>\n<p>\u8981\u83b7\u5f97 PTO \u798f\u5229\u8d44\u683c\uff0c\u4f60\u5fc5\u987b\u5c06\u586b\u597d\u5e76\u7b7e\u540d\u7684 Form W-9\uff08W-9 \u8868\u683c\uff09\u53d1\u9001\u7ed9\u6211\u4eec\uff0c\u5982\u679c\u60a8\u8fd8\u672a\u8fd9\u6837\u505a\u7684\u8bdd\u3002\u8bf7\u6ce8\u610f\uff1aPTO \u798f\u5229\u5c5e\u4e8e\u5e94\u7a0e\u6536\u5165\u3002<\/p>\n<p><a class=\"noUnderline\" href=\"https:\/\/www.carewellseiu503.org\/zh-hans\/mycarewell503\/\" target=\"_blank\" rel=\"noopener noreferrer\">\u901a\u8fc7 MyCarewell503 \u586b\u5199\u8868\u683c<\/a><\/p>\n<p>[\/et_pb_text][et_pb_text disabled_on=&#8221;off|off|off&#8221; 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