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 1-844-302-7781

ID Cards
 
EHiM ID Card Flyer Tips on understanding your updated ID card with EHiM information
Medical Benefit Information
 
Benefit Overview Provides a high level overview of your medical benefits.
Medical Enrollment Form This form is to be filled out if electing medical benefits.
Healthiestyou Healthiesyou offers unlimited access to a licensed doctor right from your phone.
PPO Plan SBC The Summary of Benefits and Coverage provides simple and consistent information about your Medical Plan, covered benefits, coverage limitations, cost sharing provisions, and exceptions.
HSA 1 Plan SBC The Summary of Benefits and Coverage provides simple and consistent information about your Medical Plan, covered benefits, coverage limitations, cost sharing provisions, and exceptions.
HSA 2 Plan SBC The Summary of Benefits and Coverage provides simple and consistent information about your Medical Plan, covered benefits, coverage limitations, cost sharing provisions, and exceptions.
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.
Prior Authorization Check Check this list to see which services DO NOT require Prior Authorization.
Health Savings Account (HSA) Forms & Information
 
HSA Enrollment Form This form is to be filled out if electing a Health Saving’s Account.
HSA Overview Provides a high level overview on HSA’s, eligible expenses, contributions, and much more.
Dental Benefit Information
 
Premier Copay Dental Benefit Overview Provides a high level overview of the Premier Copay dental plan highlights.
Premier EPO Dental Benefit Overview Provides a high level overview of the Premier EPO dental plan highlights.
Premier PPO Dental Benefit Overview Provides a high level overview of the Premier PPO dental plan highlights.
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.