2024 Annual Paperwork

2024 Annual Paperwork

Thank you for taking time to complete your Carewell Benefits annual paperwork! Completing the annual paperwork confirms that you understand and agree to the rules of the program as governed by the rules of the Trust.

Updated Trust rules will require you to provide proof of your Marketplace plan by submitting your premium bill and Marketplace Eligibility Notice in order to continue receiving Healthcare Cost Assistance benefits. Care providers who enroll in or renew an approved plan, or update their income with assistance from VIP are not required to provide this information as they will submit this information on your behalf. You'll be able to schedule this appointment at the end of completing the paperwork.

These forms also 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, Monday-Friday, 8am-6pm PST.

We're here to help!
Contact information
Name*

First NameMiddle InitialLegal Last Name
Address*

Street Address

Street Address Line 2

CityState

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

YesNo
Home address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email Address*
example@example.com
Preferred phone number*
Phone type*

CellLandline
Is it ok to leave a detailed voice message at this number?*

YesNo

Personal Information
Homecare provider number*
Please enter your homecare provider number in the box above. This is usually a 6-digit number. You can find this number on your paystub.
Date of Birth*

MonthDayYear
Date
Last four digits of Social Security Number (SSN)*
Preferred language (dropdown)*
Do you have a spouse living in your household?*

YesNo
Spouse Legal Name*
Spouse Date of Birth*

MonthDayYear
Date
How many people are in your tax-filing household?*

HIPAA Authorization Form
What is HIPAA?

The Health Insurance Portability and Accountability Act (HIPAA) was signed into law in 1996. The purpose of this law is to establish national standards to protect individuals’ personally identifiable information and to set out rules for all those who may access this information. We have you review and sign this form annually so you know what kind of data will be collected, who might have access to it, and how it will be disclosed while we assist you in enrolling in health insurance and participating in the Healthcare Cost Assistance Program.

1. WHAT MAY BE COLLECTED AND/OR DISCLOSED?

All information provided on your application for health insurance and/or enrollment is considered your protected health information, whether via website enrollment, direct enrollment, phone enrollment, or on paper, including information on all members of your tax filing household, and all past, present, and future periods of health care information (as defined by HIPAA).

2. WHO IS AUTHORIZED TO USE AND DISCLOSE PROTECTED HEALTH INFORMATION?

There are several partners who work together to ensure the Healthcare Cost Assistance Program Benefits are administered successfully. 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. Your protected health information may be disclosed/shared between Valley Insurance Professionals, RISE Partnership, Carewell SEIU 503 Benefits, the Oregon Homecare Workers Supplemental Trust, the Oregon Homecare Workers Benefit Trust and their providers, as well as with any applicable state or federal insurance marketplace or insurance exchange, or insurance company or carrier, as necessary to apply for, renew or service your insurance coverage, and/or administer your benefits for the Healthcare Cost Assistance Program.

3. WHAT IS THE PURPOSE OF THE USE OR DISCLOSURE OF MY INFORMATION?

Your information may be used or disclosed 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. HOW LONG IS THIS AUTHORIZATION VALID?

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; however, I understand my refusal may impact my ability to obtain Healthcare Cost Assistance. 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. I further understand that if I have a spouse, child(ren) or other members of my tax filing household listed on my application for health insurance, their personally identifiable information (PII) may also be disclosed to the entities listed above. I acknowledge that I have informed my spouse, child(ren) or other members of my tax filing household of this disclosure.
Signature*

Clear
Today's date*

MonthDayYear
Date

SOU data--hidden from user view
SOU-Name

First NameLast Name
SOU-Address

Mailing Address

Street Address Line 2

City, StateState / Province

Zip Code
SOU-Date of Birth

MonthDayYear
Date
SOU-Preferred Language
SOU-Email Address
example@example.com
SOU-Primary Phone

Valley Insurance Professionals 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.

Agency: Valley Insurance Professionals

Agency NPN: 13387995

Principal Agent/Broker: Lisa Schneider

Producer NPN: 14864065

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.

I further understand that if I would like more information on how compensation is calculated, I can read more in the Valley Insurance Professionals Notice of Privacy Practices. I may also call them directly at 503-480-0499 for more information.
Signature*

Clear
Today's date

MonthDayYear
Date

VIP AOR data--hidden from user view
VIP AOR-Member ID
VIP AOR-Insurance Carrier
VIP AOR-Name

First NameLast Name
VIP AOR-Date of Birth

MonthDayYear
Date
VIP AOR-Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Kaiser Permanente Agent of Record Form
Subscriber Information

Kaiser Permanente Agent of Record Authorization form

I (the subscriber) authorize the insurance agent/producer listed below 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 (KFHPNW) in connection with the purchase of the health plan coverage.

Agent/Producer Information

I (the agent/producer) have not made any representations to the applicant about any provisions, benefits, conditions, or limitations of the delivery of the policy except through written materials furnished by Kaiser Permanente. The subscriber has been informed that the effective date of the AOR is assigned by Kaiser Permanente. I certify that the information supplied to me by the applicant has been truly and accurately recorded.

Agent #: A5806 NPN: 14864065

Agency number: 00157

Agent name: Lisa Schneider, Principal Agent, Valley Insurance Professionals
Subscriber signature*

Clear

Kaiser AOR data--hidden from user view
Kaiser AOR-Date

MonthDayYear
Date
Kaiser AOR-Dec 1 Fill in Date

MonthDayYear
Date
Kaiser AOR-Health record number
Kaiser AOR-Date of birth

MonthDayYear
Date
Kaiser AOR-name
Kaiser AOR-Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Last step: Update, or enroll in, your 2024 Marketplace plan
Now you need to share information with the Marketplace to either enroll in a plan for 2024 or, if you are renewing a plan, to update the Marketplace with your most current information. There are two different ways to do this:
- You can complete your application online. This takes most people about 20-30 minutes. You will need the following information to complete your application:
  - Name
  - Date of Birth
  - Social Security Number
  - Estimated pre-tax (gross) income and deductions, including things like Social Security and Disability benefits, rental income or wages, and alimony payments
  - If anyone in your tax-filing household has access to employer coverage, you will need the employer name, employer phone number, and the monthly cost for the insurance
  - The approved plan name and ID for the plan you are enrolling in (you can find Oregon approved plans for 2024 here)
How would you like to update or enroll in your Marketplace plan?*

Complete the application online myselfI need assistance finding the best way to enrollI already scheduled my appointment with Valley Insurance Professionals and just need to submit my 2024 Annual PaperworkMy 2024 Marketplace enrollment is complete and I just need to submit my 2024 Annual Paperwork for Healthcare Cost Assistance
Important information about completing your application

Once you click "Review Before Submit" below, you will be asked to "sign" your paperwork, then rerouted to the online enrollment platform. On this platform, you can:
1. enroll in an approved Marketplace plan for 2024, or
2. if you already have an approved Marketplace plan, you can update important information like your expected 2024 income.
Note: If you would like a copy of your Annual Paperwork, click “Review Before Submit” button and on the next page, click the “Print” button to download a PDF of your submission. Please make sure to click the “Submit” button to complete your Annual Paperwork for Carewell Healthcare Cost Assistance benefits after you download your PDF.

If you have any questions during this process, call us at 1-844-503-7348, Monday-Friday, 8am-6pm PST. We're here to help.
Important information about completing your application

We can assist you in finding the best way to enroll in a Marketplace plan. Please call 1-844-503-7348, Monday-Friday, 8am-6pm PST – we’re here to help!

To complete your 2024 Annual Paperwork submission, click the “Review Before Submit” button. On the next page, if you would like a copy of your paperwork, click the “Print” button to download a PDF of your submission. Please make sure to click the “Submit” button to complete your Annual Paperwork for Carewell Healthcare Cost Assistance benefits after you download your PDF.
Would you like to have an appointment with a Valley Insurance Professionals agent in English, or do you require an interpreter?

I would like to have my appointment in English onlyI require an interpreter
Important information about completing your application

Once you click "Submit" below, you will be asked to "sign" your paperwork, then rerouted to the online platform where you can sign up for an appointment with Valley Insurance Professionals.

Note: If you would like a copy of your paperwork, click the "Preview PDF" button below before you submit. When in the preview mode, go to the upper right corner of the page and click the "arrow down" button. Then go to the upper left corner of the page and click the "Back to Form" button. Now click the "Submit" button to ensure your paperwork is submitted.

If you have any questions during this process, call us at 1-844-503-7348, Monday-Friday, 8am-6pm PST. We're here to help!
Important information about completing your application

To complete your 2024 Annual Paperwork submission, click the “Review Before Submit” button. On the next page, if you would like a copy of your paperwork, click the “Print” button to download a PDF of your submission. Please make sure to click the “Submit” button to complete your Annual Paperwork for Carewell Healthcare Cost Assistance benefits after you download your PDF.

Once you click "Submit" you will be taken to a "Thank You" page, and you can also download a copy of your 2024 Annual Paperwork from this page.

If you have any questions during this process, call us at 1-844-503-7348, Monday-Friday, 8am-6pm PST. We're here to help.
Should be Empty:

Contact information

Personal Information

Plan information

HIPAA Authorization Form

Statement of Understanding

SOU data--hidden from user view

Valley Insurance Professionals Agent of Record Form

VIP AOR data--hidden from user view

Kaiser Permanente Agent of Record Form

Kaiser AOR data--hidden from user view

Last step: Update, or enroll in, your 2024 Marketplace plan

Important information about completing your application

Important information about completing your application

Important information about completing your application

Important information about completing your application