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Eligibility and Reimbursement Appeal Form
Use this form and either fill out the field explaining why you are requesting an appeal or upload an explanation letter. Reimbursement appeals must be accompanied by supporting documentation such as an Explanation of Benefits (EOB) or proof of payment.
Form Name
Name
*
First Name
Middle Name
Last Name
Mailing address
*
Street Address
Street Address Line 2
City
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State
Zip Code
Is your home address the same as your mailing address?
*
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Home address
*
Street Address
Street Address Line 2
City
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Date of Birth
*
-
Month
-
Day
Year
Date
Provider number
Preferred phone number
*
Please enter a valid phone number.
Format: (000) 000-0000.
*
Cell phone
Landline
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. Standard message and data rates may apply. Reply STOP to end.
Email Address
example@example.com
Please check the box that best describes the reason for your appeal, submit a letter explaining the circumstances of your appeal, and provide the documentation requested for the appeal type you have chosen. If the above items are not provided, review of your appeal may be delayed. Your appeal will be decided within 30 days of receipt of all the necessary documents.
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Eligibility determination for Dental, Vision, and Employee Assistance Program benefits. Requires documentation for hours worked during the relevant period.
Reimbursement amount was paid incorrectly. Send copies of reimbursement form and documentation required from that form.
Reimbursement amount was not received. Resend the reimbursement form and all required documentation.
Eligibility determination for Healthcare Cost Assistance benefits. Requires documentation for hours worked during the relevant time period.
Appeal to enroll in a Carewell approved plan that is not in my county.
Other. Please specify in your letter the circumstances and appeal request and provide supporting documentation.
Please write the name of the plan you would like to enroll in.
Write down your reasons for requesting an appeal. Explaining the circumstances of your appeal in the box below satisfies the requirement of submitting a letter.
Upload documents here.
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