Medical Premium Reimbursement Claim Form

Medical Premium Reimbursement Claim Form

Each care provider in the household needs to complete their own reimbursement 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.
Use this form to request a Medical Premium Reimbursement if:
- You are enrolled with family members on a health insurance plan and need to be reimbursed for your individual portion of the entire premium, and/or
- You are enrolled in a plan that is non-approved and are requesting Temporary Healthcare Cost Asssistance for your premium.
You need to include proof of individual insurance coverage for each month/year for which you are requesting reimbursement, such as:
- Gross premium
- Advance Premium Tax Credit (APTC) if applicable
- Net premium
- Effective date of policy
- And the name of any person besides the care provider covered by the policy
Proof of premium and payment must specify your individual portion of the insurance bill. Carewell SEIU 503 Benefits does not provide reimbursement to individuals who are not eligible care providers.

Use this form to request a Medical Premium Reimbursement if :
- You are enrolled with family members on a health insurance plan and need to be reimbursed for your individual portion of the entire premium, and/or
- You are enrolled in a plan that is non-approved and are requesting Temporary Healthcare Cost Asssistance for your premium
Which premium(s) do you need reimbursements for:*

Your individual portion of the entire premium if you are enrolled with family members on your plan.Temporary Healthcare Cost Assistance for your premium.
Medical Premium - Reimburse Individual Portion of Family Plan

Proof of premium and payment must be provided for each month reimbursement is requested. Proof of premium and payment must specify your individual portion of the insurance bill. Carewell SEIU 503 does not provide reimbursement to individuals who are not eligible care providers.

Please select the month and year, and include the amount, you are requesting reimbursement(s) for.

Note: Requests for reimbursement must be submitted to Carewell SEIU 503. The Trusts will only allow any reimbursement or payment claims up to 1 year from the date of service.
Reimburse Individual Portion of Family Plan: Click the "Add Claim" button below if you need to claim another month/year.*
Medical Premium - Reimburse Temporary Healthcare Cost Assistance

If you qualify, you receive reimbursements for your monthly net premium up to $510 per month in 2025. You need to include proof of individual insurance coverage including the care provider’s name, the gross premium, Advance Premium Tax Credit (APTC) if applicable, net premium, effective date of your health plan, and the name of any person besides the care provider covered by your health plan. You also need to submit proof of the monthly premium payment, usually an invoice from the insurance carrier.

Please select the month and year, and include the amount, you are requesting reimbursement(s) for.

Note: Requests for reimbursement must be submitted to Carewell SEIU 503. The Trusts only allow any reimbursement or payment claims up to 1 year from the date of service.
Temporary Healthcare Cost Assistance benefits: Click the "Add Claim" button below if you need to claim another month/year.*
Include proof of individual insurance coverage for each month/year for which you are requesting reimbursement, such as:
- Gross premium
- Advance Premium Tax Credit (APTC) if applicable
- Net premium
- Effective date of policy
- And the name of any person besides the care provider covered by the policy
Directions on how to upload files

If you DO have the files online:
1. Click on “Browse Files” on this online form
2. Select the file(s) you would like to attach/upload

If you DON’T have the files online:
1. Use your phone to take a photo of any forms and documents that you need to send to us. Make sure to take a complete picture of the form and that your name is included. We can’t read or use blurry photos.
2. Click on “Browse Files” on this online form
3. Select the file(s) you would like to attach/upload
Attach/upload forms and/or documents:*

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I certify that the information provided on this form is true and that I have incurred the expenses described on this form solely relating to my own medical coverage and expenses. I also certify that I have not already received reimbursement from Carewell SEIU 503 or any other source for any of the above-listed amounts.
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MonthDayYear
Date
Medical Premium Reimbursement

Proof of premium and payment must be provided for each month reimbursement is requested.
Check here for advance reimbursement if on a family plan.
Amount in dollars for Medical Premium Reimbursement
Medical Out-of-Pocket Expenses

Up to $6,900 per year in 2023. Explanation of Benefits from your insurance company or pharmacy receipt with prescription issued must be provided with every reimbursement request.
Amount in dollars for Medical Out-of-Pocket Expenses
Upload files (proof of premium payment, explanation of benefits, pharmacy receipt) *

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Medical Premium Reimbursement Claim Form

Medical Premium Reimbursement

Medical Out-of-Pocket Expenses