Benefits Information Form

Benefits Information Form

Providing this demographic information enrolls you in Carewell SEIU 503 Dental, Vision + Hearing, and Employee Assistance Program benefits, if you are eligible and not already enrolled. This form does not enroll you in health (medical) insurance. This form also helps us to identify other Carewell SEIU 503 benefits you may qualify for. If you're currently uninsured, please contact us immediately at 1-844 503-7348 for more information about Healthcare Cost Assistance benefits.
Securely manage your benefits online with MyCarewell503. Starting July 1, 2024, the English version of this form will be available exclusively on MyCarewell503. Learn more.
Contact information
Name*

First NameMiddle NameLast Name
Mailing address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Is your home address the same as your mailing address?*

YesNo
Home address

Street Address

Street Address Line 2

CityState

Zip Code
Email address
example@example.com
Home phone number*
Please enter a valid phone number.
Cell phone number
Please enter a valid phone number.
Permission to text

Check this box to receive important updates from RISE Partnership about Carewell SEIU 503 benefits by text. You may receive up to three messages per month. Reply STOP to end.
Preferred language*

ArabicCantoneseEnglishKoreanMandarinRussianSomaliSpanishTaishanese/ToisaneseVietnameseOther
Demographic information

Providing this demographic information enrolls you in Carewell SEIU 503 Dental, Vision + Hearing, and Employee Assistance Program benefits. If you're already enrolled in these benefits, and if there are no changes to your Social Security number, date of birth, provider number, and gender, you do not need to provide your demographic information.
Do you need to submit demographic information to get enrolled in these benefits?*

No, I am already enrolled in these benefits with no changes.Yes, I need to submit demographic information to access these benefits.
Social Security Number*
ex: 111-11-1111
Date of birth*

MonthDayYear
Date
Gender*
Provider number*
Your provider number contains 6 digits.
Coverage assessment
Do you currently have health (medical) insurance coverage?*

YesNoI'm not sure
What kind of coverage do you have?*

A private plan ("Qualified Health Plan") from the federal Marketplace (healthcare.gov) or a state MarketplaceMedicare (age 65+ or disability)Medicaid (in Oregon: Oregon Heath Plan aka OHP, in Washington State: Apple Health)Dual Medicare / MedicaidEmployer insurance (not from your work as a homecare or personal support worker)Spousal coverageFamily coverageTribal / Indian Health Service (IHS)VA benefitsCOBRAOther
If you have a private plan from the federal or state Marketplace, who is your insurance carrier?
Is your current coverage ending soon?*

YesNoI'm not sure
If your current coverage ends soon, please enter end date.

MonthDayYear
Date
Do you currently receive Carewell Healthcare Cost Assistance benefits? (If you’re using a Benefit Convenience Card to pay your out-of-pocket expenses, the answer is yes.)

YesNo
Where do you live?

OregonState of WashingtonCalifornia or Idaho
In the chart above, first find your family size and follow that row over to the dollar amounts. If you earn less than the income amount listed in one column, you may be eligible for that coverage. Does it look like you may be eligible for Medicaid coverage (OHP in Oregon / Apple Health in Washington)?

YesNoI'm not sure
Are you eligible for Medicaid?*

YesNo
Before answering the Medicaid question above, check in with your state Medicaid assessment department:
- Oregon Health Authority (OHA): one.oregon.gov, 1-800-699-9075
- Washington State Health Care Authority(WA HCA): wahealthplanfinder.org, 1-855-923-4633
- Covered California: coveredca.com/health/medi-cal, 1-800-300-1506
- Idaho Department of Health and Welfare (DHW): idalink.idaho.gov, 1-877-456-1233
Are you a member of a Federally Recognized Tribe or an Alaska Native Corporation shareholder?*

YesNo
Carewell SEIU 503 Healthcare Cost Assistance is not medical insurance, it’s financial assistance to help you with certain medical costs. For more information, please visit CarewellSEIU503.org. If you need to enroll in health (medical) insurance or have questions about what your options are, call 1-844-503-7348.
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Benefits Information Form

Contact information

Demographic information

Coverage assessment