Military Connected Healthcare Cost Assistance Benefits Request Form

Carewell SEIU 503 Healthcare Cost Assistance (HCA) benefits help care providers enrolled in VA Benefits, CHAMPVA, or TRICARE to pay for covered out-of-pocket medical expenses.

For eligible care providers who have VA Benefits, CHAMPVA, or TRICARE, Healthcare Cost Assistance benefits help with the costs of:

• Out-of-pocket medical expenses, such as deductibles, copayments, coinsurance, and prescriptions for services covered by VA Benefits, CHAMPVA, or TRICARE (up to $8,000 in 2026)

Healthcare Cost Assistance amounts may change from year to year. 

For more information, please go to our Healthcare Cost Assistance for Military Connected Benefits webpage: CarewellSEIU503.org/MilitaryConnected

Use this form to request HCA benefits if you are eligible and covered by:

• VA Benefits
• CHAMPVA
• TRICARE

To request HCA benefits, use this form to upload an applicable required document:

• VA Benefits Identification Card
• CHAMPVA Identification Card
• TRICARE Identification Card (front and back)
• Form DD 214
• State-issued driver's license with “Veteran” on it
• Summary of Benefits letter
• Enrollment verification letter

To view samples of the applicable required documents, click here.

NOTE: Completing this form does not enroll you in health coverage or guarantee that you are eligible to receive HCA benefits.

If you’re eligible and approved for Healthcare Cost Assistance for VA Benefits, CHAMPVA, or TRICARE, you can submit reimbursement requests for covered medical expense retroactive to January 1, 2026 through Ameriflex. You can also access Ameriflex from your MyCarewell503 dashboard.

Use this form to upload the applicable required documentation to request Healthcare Cost Assistance (HCA) benefits for VA Benefits, CHAMPVA, or TRICARE.

• VA Benefits Identification Card 
• CHAMPVA Identification Card 
• TRICARE Identification Card (front and back)
• Form DD 214 
• State-issued driver's license with “Veteran” on it 
• Summary of Benefits letter
• Enrollment verification letter 

To view samples of the applicable required documents, click here.

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

Healthcare Cost Assistance Care Provider Agreement

The following agreement concerns my eligibility for, and participation in, the Healthcare Cost Assistance Benefits provided under the Oregon Homecare Workers Supplemental Trust (referred to in this document as “Carewell SEIU 503”).

I acknowledge:

• To be eligible for Healthcare Cost Assistance (“HCA”) benefits from Carewell SEIU 503, I must:
  

  (a) have VA health benefits, CHAMPVA health insurance, or TRICARE health insurance; and

  (b) meet all Carewell SEIU 503’s eligibility requirements, including working 40 hours or more per month. HCA benefits end one (1) month after I work less than 40 hours for 2 consecutive months.

• Trust rules require that I submit a Military Connected Benefits HCA Benefits Request with documentation of my VA, CHAMPVA, or TRICARE benefits, as applicable.
  • For proof of my Military Connected benefit, I must submit a copy of my VA, CHAMPVA, or TRICARE ID card (front and back).
• I agree to submit the necessary information to request Healthcare Cost Assistance (medical out-of-pocket expenses) through MyCarewell503 or on the CarewellSEIU503 website (CarewellSEIU503.org) in a timely manner.
• If I am approved for HCA benefits, Carewell SEIU 503 provides a Benefit Convenience Card (“BCC”) for me to pay for covered out-of-pocket medical expenses, up to the annual allowance amount. Covered out-of-pocket medical expenses include:
  • deductibles
  • copayments
  • coinsurance expenses, such as prescription drugs for claims covered by my Military Health Plan (provided the claims were incurred while I was eligible for Trust benefits).
• Any charges other than those listed above are considered unauthorized. If I use my BCC for unauthorized charges, I am liable for those overpayments of HCA benefits and am obligated to repay those unauthorized charges to Carewell SEIU 503. (See the Overpayments section in the Carewell SEIU 503 Guide to Training and Benefits.)
• I may not use my BCC to pay premium expenses or any charges for family members. Using the BCC for these expenses is unauthorized and must be repaid to Carewell SEIU 503.
• I cannot use my BCC for any expenses related to dental, vision, or hearing. Using the BCC for these expenses is unauthorized and must be repaid to Carewell SEIU 503.
• In order to receive Military Connected Benefits Healthcare Cost Assistance under Carewell SEIU 503, I cannot receive health coverage from another source, such as Medicare (Parts A and/or B), Medicaid, Marketplace coverage (HealthCare.gov), an employer, or any other type of health coverage that meets the federal minimum essential coverage (MEC) standards for insurance coverage. If I am currently enrolled in or become newly eligible for any other coverage that meets MEC standards for insurance coverage throughout the year, I must notify Carewell SEIU 503 immediately by calling them at 1-844-503-7348.
• I must review and respond to all notices I receive throughout the year from Carewell SEIU 503 and RISE Partnership to ensure there is no delay or interruption in my benefits.
• I am responsible for submitting timely and accurate information to Carewell SEIU. Failure to do so may delay my benefits. Submitting this form does not guarantee my Trust benefits and does not enroll me in the HCA benefits.