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 Progam
Healthcare Cost Assistance
Paid Time Off
COVID-19 Resources
Important – Keep your information up to date
Update Your Information
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.
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”
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Dental
Benefits Waiver Form
Review and Appeal Form
Must be submitted with a letter explaining why you are requesting an appeal.
Vision + Hearing
Benefits Waiver Form
Review and Appeal Form
Digital Form D
Must be submitted with a letter explaining why you are requesting an appeal.
VSP Member Reimbursement Form
PDF Form C
Employee Assistance Program
Benefits Waiver Form
Review and Appeal Form
Must be submitted with a letter explaining why you are requesting an appeal.
Healthcare Cost Assistance
For Approved Plans
2021 Annual Paperwork
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.
2021 HIPAA Form
2021 Statement of Understanding Form
2021 General Agent of Record Form
2021 Kaiser Permanente: Agent of Record Form
2021 Community Partner Assistance Form
2021 Oregon Health Authority Consent Form
2021 Consent to Release 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.
Ameriflex Reimbursement Form
PDF Form D
Enrollment Information Form
Medical Reimbursement Claim Form
Must be submitted with a copy of Explanation of Benefits or your bill.
Review and Appeal Form
Must be submitted with a letter explaining why you are requesting an appeal
Premium Adjustment Reimbursement Form
Must be submitted with supporting tax documents.
2020 Annual Paperwork: Inside the Kaiser Service Area
2020 Annual Paperwork: Outside the Kaiser Service Area
Healthcare Cost Assistance
For Medicare
Ameriflex Reimbursement Form
PDF Form E
Medicare Paperwork
Consent to Release 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.
Medicare Reimbursement Claim Form
Must be submitted with a copy of your premium bill.
Review and Appeal Form
Must be submitted with a letter explaining why you are requesting an appeal
Paid Time Off
PTO Beneficiary Form
PTO Beneficiary Form & Form W-9
PTO Benefit Request Form
Form W-9
COVID-19 Resources
COVID-19 PTO Benefit Request Form
For hours lost due to COVID-19 after January 1, 2021.
COVID-19 Hardship PTO Benefit Request Form
For hours due to COVID-19 lost March 10 – May 16, 2020. Requests for this benefit must be submitted by May 16, 2021.
COVID-19 Hardship PTO Verification Form
For hours due to COVID-19 lost March 10 – May 16, 2020. Requests for this benefit must be submitted by May 16, 2021.