2021 Annual Paperwork

2021 Annual Paperwork
Thank you for taking time to complete your Carewell Benefits annual paperwork! This packet contains important forms that 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.

Once you have completed this paperwork, you will be able to download a pdf of your signed documents and a copy of Valley Insurance Professional's privacy policy. If you have any questions about this paperwork, give us a call at 1-844-503-7348. We're here to help!
Contact information
Full legal name*

First NameMiddle InitialLast Name
Mailing address*

Street Address

Street Address Line 2

CityState

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
Preferred phone number*
Please enter a valid phone number.
Cell phoneLandline
Is it OK to leave a detailed message on this phone?*

YesNo

Personal information
Provider number
Date of birth*

MonthDayYear
Date
Last 4 digits of SSN*
Preferred language*
Do you have a spouse living in your household?*

YesNo
Are there other adults listed on your Marketplace insurance application?*

YesNo
Names of other adults on your application:
First Name   Last Name
First Name   Last Name
First Name   Last Name
First Name   Last Name
Total number of household members:*
Number of household members over the age of 18:*
Do you have income, contact, household, or other life changes to report?*

NO: I do not have changes to report; please update my Advance Premium Tax Credits.YES: I have changes to report; please contact me to schedule an appointment.

HIPAA Authorization Form
I hereby authorize the use or disclosure of my protected health information as described below:
1. AUTHORIZED PERSONS TO USE AND DISCLOSE PROTECTED HEALTH INFORMATION
  Valley Insurance Professionals, Inc. is authorized to disclose the following protected health information to RISE Partnership, the Oregon Homecare Workers Supplemental Trust, the Oregon Homecare Workers Benefit Trust and their providers, and any applicable state or federal insurance marketplace or insurance exchange, or insurance company or carrier.
2. DESCRIPTION OF INFORMATION TO BE DISCLOSED
  All information provided on your application for health insurance, whether via website enrollment, direct enrollment, phone enrollment, or on paper; including information on all members of your tax filing household. All past, present, and future periods of health care information (as defined by HIPAA).
3. PURPOSE OF THE USE OR DISCLOSURE
  The purpose of this use or disclosure is to assist RISE Partnership, the Oregon Homecare Workers Supplemental Trust and the Oregon Homecare Workers Benefit Trust in the administration of your benefits under the applicable Trusts.
4. VALIDITY OF AUTHORIZATION FORM
  This Authorization Form is valid beginning the date of this Agreement and expires ten years from the date of execution of this Authorization Form.
5. ACKNOWLEDGMENT
  I understand that the information used or disclosed under this Authorization Form may be subject to re-disclosure by the person(s) or facility receiving it, subject to the federal privacy regulation. I have the right to refuse to sign this Authorization Form. If signed, I have the right to revoke this authorization, in writing, at any time. I understand that any action already taken in reliance on this authorization cannot be reversed, and my revocation will not affect those actions.
Care provider signature*

Clear
Use your cursor (on a computer), stylus or finger (on a tablet or smart phone) to sign your name in the field above.
Date of care provider signature

MonthDayYear
Date
Name

First NameLast Name
Name

First NameMiddle NameLast Name
Date of birth

MonthDayYear
Date
Spouse full legal name

First NameLast Name
Spouse date of birth

MonthDayYear
Date
Spouse signature (if spouse is in household)

Clear
Use your cursor (on a computer), stylus or finger (on a tablet or smart phone) to sign your name in the field above.
Date of spouse signature

MonthDayYear
Date

Statement of Understanding

Continued
The following section pertains to my Marketplace application for health insurance, whether via website enrollment, direct enrollment, phone enrollment, or on paper. The term “eligibility,” when used below, shall be in reference to Marketplace eligibility and not Carewell SEIU 503 benefits:*

I am authorizing the team of agents at Valley Insurance Professionals to assist with my Marketplace eligibility determination and/or enrollment in a Qualified Health Plan ("QHP"). This authorization includes a) conducting online person searches to access my current and/or any previous year’s Marketplace enrollment using my Personally Identifiable Information (“PII”); b) completing a Marketplace eligibility determination, plan selection, and/or enrollment; c) ongoing account/enrollment maintenance or; d) verifying prior coverage/application information.I am signing or authorizing my application under penalty of perjury, which means I have provided true answers to all the questions on the application to the best of my knowledge. I know that I may be subject to penalties under federal law if I intentionally provide false or untrue information.I understand that I am not eligible to be enrolled in a Marketplace plan if I am enrolled in Medicare Part A and/or B.I know that I must tell the Health Insurance Marketplace if anything changes or is different than what I provide on my application within 60 days of the change. I may contact Valley Insurance Professionals to update my information or I can visit HealthCare.gov or call 1-800-318-2596 to report any changes. I understand that a change in my information could affect my eligibility, and the eligibility of member(s) of my household.To make it easier to determine my eligibility for help paying for health coverage in future years, I agree to allow the Marketplace to use income data, including information from my tax returns, for the next 5 years (the maximum number of years allowed). The Marketplace will send me a notice and let me make any changes, and I can opt out at any time. If I choose to opt out, my QHP may not auto-enroll the following year, so I must take action each year during Open Enrollment to ensure I am enrolled in health insurance coverage.
OK to leave msg on landline
NOT OK to leave msg on landline
OK to leave msg on cell
NOT OK to leave msg on cell
Care provider signature*

Clear
Use your cursor (on a computer), stylus or finger (on a tablet or smart phone) to sign your name in the field above.
Date*

MonthDayYear
Date
Name

First NameMiddle NameLast Name
Address

Street Address

Street Address Line 2

CityState

Zip Code
Date of birth

MonthDayYear
Date
Email
example@example.com
Home phone
Please enter a valid phone number.
Cell phone
Please enter a valid phone number.

Community Partner Assistance Consent Form
Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.
Email
example@example.com
Applicant Consent

I authorize the Community Partner Organization listed above (RISE Partnership) to see and use my personally identifiable information (PII) and protected health information (PHI) to help me apply for health insurance. I understand the Community Partner Organization will make sure any stored personal information is kept private and secure. I understand that I may revoke, or otherwise limit, the consent provided with this form at any time. If I do this, I understand that I must notify the Community Partner Organization of the change. I understand that I am responsible for reporting accurate information on this form.

Assister Obligation

The Certified Application Counselor (Assister), in affiliation with the Community Partner Organization, listed above, will:
- Inform me and/or my authorized representative about the full range of Marketplace health coverage options and financial assistance I may qualify for;
- Help me complete my application for health coverage in a Qualified Health Plan (QHP);
- Help me enroll in a QHP and financial assistance (if eligible);
- Help me in the language I prefer or refer me to someone who can;
- Inform me and/or my authorized representative of any potential conflicts of interest.
The Assister will not:
- Charge me and/or my authorized representative any fee for assistance;
- Choose or recommend a health plan for me;
- Discriminate based on age, gender identity, sexual preference, religious or political affiliation, race, color, national origin, or disability.
Signature*

Clear
Use your cursor (on a computer), stylus or finger (on a tablet or smart phone) to sign your name in the field above.
Date*

MonthDayYear
Date

OHA Community Partner Assistance Consent
Name

First NameLast Name
Date of birth

MonthDayYear
Date
Phone Number
Please enter a valid phone number.
APPLICANT: I agree to let the Community Partner Organization (RISE Partnership) listed above see and use my personal information to help me apply for health coverage.

If applying for, enrolling in, maintaining, and/or changing my health coverage through a Public Medical Program (includes the Oregon Health Plan, CAWEM, and CAWEM Plus): I agree to let the Oregon Health Authority (OHA) share my application, enrollment details and status, plan benefits, and protected health information with the Community Partner Organization and Application Assister listed above. The Community Partner Organization is required to protect and keep any signed information private. I authorize OHA to add this Community Partner Organization and the Application Assister identified above to my case file confirming that I allow this disclosure.

I understand that the Community Partner Organization and the individual Application Assister will:
- Tell me about what health insurance and financial help I may qualify for;
- Help me enroll in and share my application information with a Public Medical Program or a Qualified Health Plan (QHP);
- Help me in the language I prefer or refer me to other partners who can help me in the language I speak and understand.
I understand that the Community Partner Organization and the individual Application Assister MAY NOT:
- Charge me a fee for any assistance provided;
- Choose or recommend a health insurance plan for me.
I understand that I must report accurate information on this application, and I must respond to any notice of missing or inaccurate information, when asked.

I may cancel permission for the Community Partner Organization to help me at any time if I am enrolled in a Public Medical Program. If I cancel this permission, I will tell OHA by calling 1-800-699-9075 or by faxing my request to 503-378-5628.

I understand that if I cancel my permission it will not apply to information that was already shared by OHA with the Community Partner Organization or Application Assister. I also understand that information OHA receives may be shared with the Community Partner Organization or Application Assister as well, and that the Community Partner Organization or Application Assister may share this same information. OHA will not share information about mental health, HIV/AIDS, drug and alcohol treatment, or genetic testing without first getting authorization from me to do so.
Signature*

Clear
Use your cursor (on a computer), stylus or finger (on a tablet or smart phone) to sign your name in the field above.
Date*

MonthDayYear
Date

Consent to Release Information

This form is optional
Respecting and protecting your privacy is vital to us, and we take our responsibility to protect the privacy and confidentiality of your information very seriously. By the Trusts’ policies and by law we cannot release your personal information, including your personal health information, to anyone other than you, except where it is allowed by law. However, we understand that there may be times when it is more convenient for you to have a trusted family member or friend make inquiries, schedule appointments, or confirm information on your behalf. This Consent to Release Information form is optional and designed for you to let us know who you trust with your confidential information.
CTRI
Name

First NameLast Name
Date

MonthDayYear
Date
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.
By completing this form, you consent to release information to:
Legal name

First NameLast Name
Date of birth

MonthDayYear
Date
Mailing address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.
Email
example@example.com
Relation to you
By signing this consent form you are agreeing that the following information may be discussed with the person you have chosen above. This person may:
- Discuss with the Carewell SEIU 503 benefits team, and/or any of the Partners specifically designated below, any information relating to your participation in, and your receipt of Carewell SEIU 503 benefits, including but not limited to, your name, date of birth, Social Security number, income, address, phone number, and email address.
- Discuss with the Carewell SEIU 503 benefits team and/or any of its Partners specifically designated below the details of the insurance policy for which you have applied, or for which you are in the process of applying, through the applicable state or federal Healthcare Marketplace, including but not limited to, coverage lines available to you, name of Insurance Carrier, insurance plan information, payment/billing details, premium amount, and federal premium tax credits available to you (if applicable).
- Set appointments for you with the benefits team or one of its Partners.
This consent form does not allow the person you have named above to:
- Enroll you in coverage, terminate your coverage, or change your coverage selection.
- Sign any documents on your behalf, unless the person has a valid Power of Attorney document giving them this authority and you have provided a copy of such Power of Attorney document to Carewell SEIU 503.
- Speak to the Benefit Convenience Card issuer (Ameriflex), Insurance Carrier, or the Health Insurance Marketplace on your behalf. These entities have their own guidelines for consent that must be followed when speaking with them.
I understand that I am consenting to the release of the information described on this form to the person I have named. This consent is valid until such time as I contact the Benefits Administrative Office in writing to make changes and/or terminate this consent. I understand I have the right to refuse to sign this form. If signed, I have the right to revoke this authorization, in writing, at any time. I understand I am not required to sign this form to receive my benefits, nor does signing this form alter my enrollment in Carewell SEIU 503 benefits, my eligibility, or any payments I may owe under the Trust(s).
I also understand I am giving consent to RISE Partnership, and the following Partners to speak to the person I have named above (check all that apply):

Carewell SEIU 503 benefits teamBenefits Administrative Office (Vimly)Valley Insurance ProfessionalsMember Assistance Center
Signature

Clear
Use your cursor (on a computer), stylus or finger (on a tablet or smart phone) to sign your name in the field above.
Date

MonthDayYear
Date
Should be Empty:

2021 Annual Paperwork

Contact information

Personal information

HIPAA Authorization Form

Statement of Understanding

Statement of Understanding

Agent of Record Form

Community Partner Assistance Consent Form

OHA Community Partner Assistance Consent

Consent to Release Information