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

2023 Medical Benefit Information
 
2023 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.
2023 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.
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.
Claim Reimbursement Forms
 
Medical & Dental Expense form Fill out the Expense Reimbursement Form and submit to HealthEZ when you have paid out of pocket for Medical and/or Dental expenses.
Prescription Reimbursement Form Fill out the Prescription Reimbursement Form and submit to your Pharmacy Benefit Manager (PBM) when you have paid out of pocket for prescription expenses.
Preventative Wellness Services
 
Preventative Wellness Services Provides information on your common preventative wellness services.
Important Notices
 
Precertification List Procedures that commonly require precertification
Your Rights and Protections Against Surprise Medical Bills When you get emergency care or get treated by an out-of-network provider at an in-network hospital or ambulatory surgical center, you are protected from surprise billing or balance billing.
Notice of Electronic Disclosure Notice of Electronic Disclosure of Employee Benefit Notices, Summary Plan Description and Plan Amendments
Paper Employee Notices Acknowledgement of Paper Employee Benefit Notices
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
COBRA Notice Explains your right to continue health benefits, if you were to lose them through your group health plan.
Health Insurance Portability and Accountability Act of 1996 (HIPAA) Notice Explains how personal health information about you may be used and disclosed.
Newborn Act Notice Explains how important protections for your members and their newborn children.
Special Enrollment Notice Explains your right to enroll in your group health plan, if you lose your "other" health coverage.
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.