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  • 2025 Annual Paperwork

    By completing Carewell’s 2025 Annual Paperwork, you are taking the first step to find a Carewell-approved Marketplace health (medical) insurance plan, and the financial support to put it in place!

    This paperwork is not an application for health (medical) insurance. You need to enroll on the Marketplace for this coverage. When you enroll in a Carewell-approved Marketplace plan, you can request Carewell’s Healthcare Cost Assistance benefits. If eligible, this benefit covers 100% of your net monthly medical premiums, as well as $7,165 in 2025 for covered out-of-pocket medical expenses.

    This form does not cover Dental Insurance. If you're eligible for Healthcare Cost Assistance, you most likely have Dental Insurance from Carewell. Please reach out to Carewell to confirm whether you already have Dental Insurance before selecting a plan on the Marketplace.

    Submitting the 2025 Annual Paperwork confirms that you understand and agree to the rules of the program. These forms also give the Carewell SEIU 503 Benefits team and our partners permission to assist you with enrolling in and maintaining your healthcare coverage. 

    Trust rules require you to provide proof of your Marketplace plan by submitting your premium bill and Marketplace Eligibility Notice to receive Healthcare Cost Assistance benefits. Care providers who enroll in or renew an approved plan, or update their income, with assistance from Valley Insurance Professionals (VIP) have this information submitted by VIP on their behalf. 

    Once you have completed the 2025 Annual Paperwork, you can 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

  • Personal Information

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  • Plan information

  • BEFORE CHOOSING AN APPROVED PLAN: Take a moment to review the Carewell-approved Silver health (medical) insurance plans on the Marketplace for your county. 

    1. Select your county on the dropdown list below.
    2. Review the 2025 Approved Marketplace Silver plan(s) available to you.
    3. Choose an approved plan.

    Once you select your county, you can also review and download the Summary of Benefits for each plan available. The Summary of Benefits is a document that provides details about a plan.

  • 2025 Kaiser Permanente OR Silver 3000 (OR)

    Plan ID 71287OR0420011

    Download Summary of Benefits and Coverage (document provides details to plan)

     

  • 2025 Providence Oregon Standard Silver - Choice Network (OR)

    Plan ID 56707OR1330004

    Download Summary of Benefits and Coverage (document provides details to plan)

     

  • 2025 Providence Oregon Standard Silver - Signature Network (OR)

    Plan ID 56707OR1360004

    Download Summary of Benefits and Coverage (document provides details to plan)

  • 2025 PacificSource OR Standard Silver Plan NAV (OR)

    Plan ID 10091OR0750013

    Download Summary of Benefits and Coverage (document provides details to plan)

  • 2025 Regence Standard Silver Plan Individual and Family Network - EPO (OR)

    Plan ID 77969OR5290001

    Download Summary of Benefits and Coverage (document provides details to plan)

  • 2025 Regence Cascade Silver Individual and Family Network (WA)

    Plan ID 71281WA1360014

    Download Summary of Benefits and Coverage (document provides details of plan)

     

  • 2025 Kaiser Permanente Cascade Silver (WA)

    Plan ID 23371WA1940002

    Download Summary of Benefits and Coverage (document provides details to plan)

  • 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 (also known as “Carewell SEIU 503”), 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 (also known as “Carewell SEIU 503”), 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 (10) 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.

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  • Statement of Understanding

  • Relating to the Oregon Homecare Workers Supplemental Trust & Carewell SEIU 503 Benefits

    The following section pertains to my eligibility for, and participation in, the Healthcare Cost Assistance Benefits, provided under the Oregon Homecare Workers Supplemental Trust “Trust.”

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  • CONSENT FOR BROKER ASSISTANCE

    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”) and Carewell SEIU 503 Benefits, 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, working under Lisa Schneider, as the Principal Broker (NPN: 14864065), that are assigned to assist care providers and their families. The following section pertains to my Marketplace application for health insurance, whether via website enrollment, direct enrollment, phone enrollment, or on paper. The term “eligibility,” when used below, shall be in reference to Marketplace eligibility and not Carewell SEIU 503 benefits, funded by the Trusts:

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  • SOU data--hidden from user view

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  • Broker Consent data - hidden from user view

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  • Agent of Record Change Form

    Valley Insurance Professionals
  • New Agent Information (All fields required)

    Agency Printed Name: Valley Insurance Professionals

    Agency National Producer Number (NPN): 13387995

    Agent’s Printed Name: Lisa Schneider

    Agent National Producer Number (NPN): 14864065

    Email: HCWenroll@valleyinsurancepro.com

    Phone: (503) 974-8471

    Reason for AOR (Required):

    To assist with the administration of Healthcare Cost Assistance Benefits, in partnership with Carewell SEIU 503 Benefits and funded by the Oregon Homecare Workers Supplemental Trust.
     

    This is a request to assign the above-named agent as the Agent of Record for the policyholder named above. This appointment removes any prior agent and is continuous until another agent is designated by the policyholder. This Agent and the Agency listed above 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 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. 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.

    Important Note: The AOR change will be effective on the first of the month following the date the member signed the AOR form.

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  • VIP AOR data--hidden from user view

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  • 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

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  • Kaiser AOR data--hidden from user view

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  • Last step: Update, or enroll in, your 2025 Marketplace plan

  • Now you need to share information with the Marketplace to either enroll in a plan for 2025 or, if you are renewing a plan, to update the Marketplace with your most current information. You need the following info for you and your tax-filing household to complete your application for any option you choose to enroll in your Marketplace Silver Plan:

    • Name
    • Date of Birth
    • Social Security Number
    • Immigration documentation, if applicable
    • Estimated pre-tax (gross) income and deductions, including things like Carewell PTO benefits, 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 2025 here)
  • Once you click "Review Before Submit" below, you are asked to "sign" your paperwork by clicking “Submit.” You are then taken to the beginning of the 2025 Annual Paperwork to complete another application for a care provider in your household.

    When you have completed all 2025 Annual Paperwork submissions, you can then choose your enrollment path when you submit the last one.

  • Important information about completing your application

    Once you click "Review Before Submit" below, you are asked to "sign" your paperwork by clicking “Submit,” then routed to the online form needed by Valley Insurance Professionals to complete your enrollment. In this form, you can:

    • choose a Carewell-approved Marketplace plan for 2025;
    • an option to sign up for an enrollment appointment with Valley Insurance Professionals.

    Valley Insurance Professionals completes the enrollment and sends an email for you to review and confirm your enrollment application and plan selection is correct. 

    Note: If you would like a copy of your Annual Paperwork, click the “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

    Once you click "Review Before Submit" below, you are asked to "sign" your paperwork by clicking “Submit,” then routed to the online form needed by Valley Insurance Professionals to complete your enrollment. In this form, you can:

    • choose a Carewell-approved Marketplace plan for 2025;
    • sign up for an enrollment appointment with Valley Insurance Professionals. 

    Note: If you would like a copy of your Annual Paperwork, click the “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

    If you are renewing your Carewell-approved plan from 2024, you most likely have a passive renewal with the Marketplace. This means your health insurance for 2025 should be in place.

    Please review the following and confirm that you meet these criteria:

    • You are still enrolled and up to date on your premiums.
    • You are renewing coverage just for yourself (not adding/changing coverage for family members).
    • You are in an approved plan for your area.
    • You have updated your info with the Marketplace in the last two years.

    Since you will be receiving a raise in January, you can schedule an income update appointment with Valley Insurance Professionals (VIP) after January 15, 2025.

    Note: If you would like a copy of your Annual Paperwork, click the “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

    You have the option to provide the required documents for your Healthcare Cost Assistance benefits 2025 request by attaching/adding them in the boxes below. The required documents are:

    1. A copy of your 2025 Marketplace Eligibility Notice
    2. A copy of your 2025 premium bill/invoice

    Once you click "Review Before Submit" below, you are asked to "sign" your paperwork by clicking “Submit.” You are then taken to a "Thank You" page and you can download a copy of your 2025 Annual Paperwork. 

    Note: Another way to download a copy is to click the “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

    Once you click "Review Before Submit" below, you are asked to "sign" your paperwork by clicking “Submit.” You are then taken to a "Thank You" page and you can download a copy of your 2025 Annual Paperwork. 

    Note: Another way to download a copy is to click the “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. Please call 1-844-503-7348, Monday-Friday, 8am-6pm PST – we’re here to help!

    Before you call, complete your 2025 Annual Paperwork submission.

    1. To complete click the “Review Before Submit” button.
    2. On the next page, if you would like a copy of your paperwork, click the “Print” button to download a PDF of your submission.
    3. 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 would like to provide the required documents for your Healthcare Cost Assistance benefits 2025 request, add files below.

    To view samples of the Marketplace Eligibility Notice and the premium bill, click here.

    Directions on how to add files

    If you DO have the files on your device:
    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 on your device:
    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 “Add Files” on this online form
    3. Select the file(s) you would like to attach/add

  • Add Files
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