Benefits Waiver Form

Benefits Waiver Form
Form Name
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.
Name

First NameLast Name
Mailing address

Street Address

Street Address Line 2

CityState

Zip Code
Is your home address the same as your mailing address?
Home address

Street Address

Street Address Line 2

CityState

Zip Code
Date of Birth

MonthDayYear
Date
Social Security Number Deprecated
Social Security Number
Preferred Language
Provider number
Preferred Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email Address
example@example.com
I acknowledge that I have been offered Carewell SEIU 503 Dental, Vision+Hearing, and Employee Assistance Program (EAP) coverage through the Oregon Homecare Workers Benefit Trust. By my signature below, I am declining this coverage because:

Other (specify reason):
By signing below, I understand that I am voluntarily waiving my right to coverage for which I am otherwise eligible through the Oregon Homecare Workers Benefit Trust.
Signature

Clear
Date

MonthDayYear
Date
Should be Empty: