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 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
 
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