Form Library

Everything you need in one place.

Below you’ll find links to information and forms, which you can view or download and print.

If you prefer talking with a HealthEZ representative, call 1-844-449-5545

Medical Benefit Information
 
Benefit Overview Provides a high level overview of your HealthEZ medical benefits.
Enrollment Form This form is to be filled out if electing medical benefits.
HDHP Plan 1 SBC Provides an easy-to-understand summary about a health plan’s benefits and coverage.
HDHP Plan 2 SBC Provides an easy-to-understand summary about a health plan’s benefits and coverage.
Prior Authorization Check Check this list to see which services DO NOT require Prior Authorization.
Summary Plan Description (SPD) Provides information on how the medical plan operates, when employees are eligible for benefits, how benefits are paid, and much more.
Teledoc Health COVID-19 Response If you think you’ve been exposed to the coronavirus, it’s important to reach out to a healthcare provider like HealthiestYou.
Dental Forms & Information
 
DenteMax Overview Provides a high level overview of your DenteMax dental benefits.
DenteMax FAQ Frequently asked questions about DenteMax dental services.
Dental Summary Plan Description (SPD) Provides information on how the dental plan operates, when employees are eligible for benefits, how benefits are paid, and much more.
Important Notices
 
Notice of Electronic Disclosure Notice of Electronic Disclosure of Employee Benefit Notices, Summary of Plan Description, and Plan Amendments.
Paper Employee Notice Acknowledgement of Paper Employee Benefit Notices.
COBRA Notice Explains your right to continue health benefits, if you were to lose them through your group health plan.
Special Enrollment Notice Explains your right to enroll in your group health plan, if you lose your "other" health coverage.
Children´s Health Insurance Program (CHIP) Notice Explains how your eligibility for Medicaid or CHIP may qualify you for premium assistance to pay for your employer's health coverage.
Newborn Act Notice Explains important protections for mothers and their newborn children.
Health Insurance Portability and Accountability Act of 1996 (HIPAA) Notice. Explains how medical information about you may be used and disclosed.
The Genetic Information Nondiscrimination Act (GINA) Booklet Explains how discrimination on genetic information is prohibited in group health plan coverage.
Women´s Health and Cancer Rights Act of 1998 Explains important protections for those who choose to have breast reconstruction, in connection with a mastectomy.