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.
Claim Reimbursement Form This form is to be filled out when needing reimbursements for medical, dental or pharmacy expenses.
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
 
Paper Employee Benefit Notices Acknowledgement of Paper Employee Benefit Notices
Notice of Electronic Disclosure Notice of Electronic Disclosure of Employee Benefit Notices, Summary Plan Description, and Plan Amendments
CHIP Model Notice Premium Assistance under Medicaid and the Children’s Health Insurance Program
COBRA Notice General COBRA Notice
GINA Booklet The Genetic Information Nondiscrimination Act
HIPAA Notice HIPAA Privacy Notice
Newborns Act Newborns’ and Mothers’ Health Protection Act
Special Enrollment Rights Notice Special Enrollment Rights Notice
WHCRA Women’s Health and Cancer Rights Act