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 1-844-801-1908

Medical Benefit Information
 
Benefit Overview Provides a high level summary of your medical plans benefits.
Medical Enrollment Form This form is to be filled out if electing medical benefits.
EZSPD An EZ to understand, short version of your Legal SPD.
Medical Copay Plan SBC The Summary of Benefits and Coverage provides simple and consistent information about your Medical Copay Plan, covered benefits, coverage limitations, cost sharing provisions, and exceptions.
Medical Bronze Copay Plan SBC The Summary of Benefits and Coverage provides simple and consistent information about your Medical Bronze Copay Plan, covered benefits, coverage limitations, cost sharing provisions, and exceptions.
Diabetes Program Diabetes Program will match you with a health coach to help with managing your diabetes.
Pharmacy Documents
 
EHiM Mail Service Overview Provides on overview on the benefits of EHiM Mail Service.
EHiM Generics This guide provides information on how to save money by choosing quality, cost-effective alternatives to brand medications.
Medicare Part D Notice This notice has information about your current prescription drug coverage and about your options under Medicare’s prescription drug coverage.
Plan Documents
 
Summary Plan Description Provides information on how the medical plan operates, when employees are eligible for benefits, how services and benefits are calculated, when benefits become vested, when and in what form benefits are paid, how to file claims for benefits, and much more.
Marketplace Notice Explains options for purchasing health coverage through the Insurance Marketplace.
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.