Enrollment Information Form

Enrollment Information Form
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The information you need to provide to the Benefits Administrative Office includes your current medical coverage insurance plan name, your premium amount, tax subsidy amount, and the start date of your coverage for that premium amount. You can get this information from your insurance carrier or your Health Insurance Marketplace. Note: Once you submit this information and it is received by the Benefits Administrative Office, it can take up to 20 business days to see that information reflected on your Benefit Convenience Card.

IMPORTANT: If you have not already done so, please fill out the annual pre-enrollment paperwork (HIPAA, Statement of Understanding, Agent of Record and Consent forms) for your area:
- 2021 Annual Paperwork
Why are you completing this form? *

I am enrolling in Carewell SEIU 503 Healthcare Cost Assistance benefits for the first time I have updated my enrollment information (e.g., changed income amount, changed name) I have changed my coverage (e.g., to Medicaid, Medicare, or an employer-sponsored plan) I have changed plans (i.e., moved from one individual Marketplace plan to another) I am reporting my new premium information for 2021

Legal name *

First Name Last Name
Home phone number *

Area Code Phone Number
Cell phone number

Area Code Phone Number
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 *
example@example.com
Provider number *
Social Security Number *

Personal Information

Use this form after you have updated your information with the Health Insurance Marketplace to inform the Benefits Administrative Office of potential changes to your medical premium information or changes in your medical coverage. This information will be used to update your information and benefits in the system. PLEASE NOTE: This form should be completed after you enroll in a Marketplace plan. Completing this form does not enroll you in coverage or benefits.
Gender *

Female Male
Date of birth *

Month Day Year
Date
Preferred language
Mailing address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Is your mailing address the same as physical address? *

Yes No
Physical address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code

Premium Information

You will get a bill from your insurance carrier once your enrollment or re-enrollment information is processed. The Benefits Administrative Office will need to know your monthly premium information to update the benefits on your Benefit Convenience Card.

You should be able to find most of the following information in a letter from your insurance carrier or in your healthcare.gov account.
Insurance plan base premium (gross) amount *
Enter the dollar amount of your base (i.e. gross) premium here. You should be able to find this information in a letter from your insurance carrier or in your healthcare.gov account
Insurance plan Advanced Premium Tax Credit (APTC or subsidy) amount *
Enter the dollar amount of your APTC here. You should be able to find this information in a letter from your insurance carrier or in your healthcare.gov account
Total net premium (cost of the premium that you pay every month) *
This is the amount calculated based on the amounts you entered above for your base premium and Advanced Premium Tax Credit. If you believe the amount of your net premium is incorrect, please double-check your response to the base premium and APTC questions.

Family Information

You will be reimbursed only for your portion of the premium, and not the cost for family coverage. Please fill out the information below to alert the Benefits Adminstrative Office if you have multiple people enrolled on your insurance plan.
Number *
This includes yourself; cannot be less than 1.
Do you have any family members enrolled on your plan that are not Trust eligible Homecare or Personal Support Workers? *

No Yes
Notes

Personal Information