Language
  • English (US)
  • Chinese
  • Russian
  • Español
  • Vietnamese
  • 2022 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

  • Personal information

  •  - -
  • Names of other adults on your application:
        
         
          
          

  • 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
      As licensed insurance agents, Valley Insurance Professionals, Inc. may collect your protected health information through the process of assisting you or your family to apply for health insurance. Valley Insurance Professionals is authorized to disclose the protected health information listed below to RISE Partnership, Carewell SEIU 503 Benefits, the Oregon Homecare Workers Supplemental Trust, the Oregon Homecare Workers Benefit Trust and their providers, and/or any applicable state or federal insurance marketplace or insurance exchange, or insurance company or carrier necessary to apply for, renew or service your insurance coverage.
    2. DESCRIPTION OF INFORMATION TO BE DISCLOSED
      All information provided on your application for health insurance and/or enrollment, 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, Carewell SEIU 503 Benefits, 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.
  • Clear
  •  - -
  •  - -
  •  - -
  • Clear
  •  - -
  • Statement of Understanding

    Relating to Oregon Homecare Workers Supplemental Trust
  • I, the undersigned, hereby authorize the team of agents at Valley Insurance Professionals (“VIP”), the insurance broker for the Oregon Homecare Workers Supplemental Trust (“Trust”), to act as my “Agent of Record” relating to any health insurance plan in which I enroll, whether I apply directly or through the applicable federal or state Marketplace. I understand that VIP has a team of licensed insurance agents assigned to assist care providers and their families.

  • Statement of Understanding

    Continued
  • Clear
  •  - -
  •  - -
  • Agent of Record Form

  • I hereby appoint the Agent/Producer listed below as Agent of Record, effective immediately, for purposes of arranging and servicing my insurance coverage for me and/or my family. This Agent/Producer and the Agency listed below may share enrollment, disenrollment, and summary plan information specific to me and/or my family, with the insurance carrier I have chosen. 

    I understand that the insurance agent/producer of record may receive monetary and/or nonmonetary payments from the insurance carrier listed above in connection with the purchase of the health plan coverage. This compensation does not affect the price of my insurance, which is set by the insurance carrier and approved by the Insurance Division of the State in which I live. This appointment rescinds all previous appointments and shall remain in effect until termination by either party.

    Agency: Valley Insurance Professionals                 Agency NPN: 13387995

    Principal Agent/Producer: Lisa Schneider               Agent NPN: 14864065

     

  • Clear
  •  - -
  •  - -
  • I (the subscriber) authorize the insurance agent/producer listed above to share enrollment, disenrollment, and summary plan information specific to the applicant with the insurance carrier.

    I understand that the insurance agent/producer of record may receive monetary and/or nonmonetary payments from Kaiser Foundation Health Plan of the Northwest (FHPNW) in connection with the purchase of the plan coverage.

  •  - -
  • Clear
  • Community Partner Assistance Consent Form

  • 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.
  • Clear
  •  - -
  • OHA Community Partner Assistance Consent

  •  - -
  • APPLICANT: I agree that my community partner organization (RISE Partnership) and application assister listed above can see and use my information. This will help me apply for health coverage.

    I want to apply for, enroll in, continue, or change a health coverage below for: 

    • Oregon Health Plan (OHP)
    • Citizen Alien Waived Emergent Medical (CAWEM)
    • CAWEM Plus, or
    • A qualified health plan (QHP).

    I will let the Oregon Health Authority (OHA), Oregon Department of Human Services (ODHS), and Oregon Health Insurance Marketplace (OHIM) share my information below, as needed, with my community partner organizaion and application assister:

    • My application
    • Enrollment details
    • Enrollment status
    • Plan benefits, and
    • Protected health information (PHI).

    Note: The above organizations must protect and keep my information private.

    I will let OHA and ODHS add this community partner organization and application assister to my case file.

    I understand:

    • My community partner organization and application assister will:
      • Tell me what health coverage and financial help I may qualify for
      • Help me enroll in and share my application information with a public health plan or a QHP, and
      • Help me or refer me to other partners who can help me in a language I speak, understand or prefer.
    • My community partner organization and application assister may not:
      • Charge me a fee for any help, or
      • Choose or recommend:
        • A coordinated care organization (CCO), or
        • A health insurance plan for me.
    • I must state correct information on my application.
    • I must respond to any notice of missing or incorrect information, when asked.
    • I may cancel my authorization for my community partner organization to help me at any time:
      • If I am enrolled in a public health plan, and
      • If I request in one of the ways below:
        • Phone: 1-800-699-9075, or
        • Fax: 503-378-5628.
      • Note: Canceling would not apply to information already shared.
    • OHA/ODHS may share information it gets with my community partner organization or application assister. They may then share this same information.
    • OHA/ODHS will not share information about the below without first getting authorization:
      • Mental health
      • HIV or AIDS
      • Drug and alcohol treatment, or
      • Genetic tests.

    My authorization is valid from the date I sign until:

    • I tell OHA or ODHS I no longer want to work with this community partner, or
    • I ask another community partner for help. 
  • Clear
  •  - -
  • 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.

  •  - -
  • This form is optional. By completing it, you consent to release information to:

  •  - -
  • 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).

  • Clear
  •  - -
  •  
  • Should be Empty: