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.
Medicare Disclosure Notice (Creditable) This is a notice in regards to your prescription drug coverage an about your options under Medicare's prescription drug coverage.
Medicare Disclosure Notice (Non-Creditable) This is a notice in regards to your prescription drug coverage an about your options under Medicare's prescription drug coverage.
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.
Claim Reimbursement Forms
 
Medical Expense Reimbursement Form Fill out the Medical Expense Reimbursement Form and submit to HealthEZ when you have paid out of pocket for medical 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.
COVID-19 OTC Test Claim Reimbursement Form Use this form for your over-the-counter Covid-19 test reimbursement.
Telemedicine
 
You've Got Teladoc Talk to a doctor anytime, anywhere by phone or video.
Mobile App Set Up Use this flyer to help set up the Teladoc Mobile App
Teladoc Web Registration It’s quick and easy to set up your account online. Simply visit the Teladoc® website.
Machine Readable File
 
Machine Readable File - Aetna Network Machine Readable Files, published in accordance with the Transparency in Coverage final rule. The information contained in the files is accurate as of the “Last Updated” date and is subject to change at any time and without notice.
PLEASE NOTE: Due to the amount of information contained in these files, some may be as large as one Terabyte (TB) in size. Please ensure you have the required memory capacity, hardware, and software capabilities before attempting to download. The Machine Readable Files are formatted to allow researchers, regulators, and application developers to more easily access and analyze data.
Machine Readable File - Out of Network Machine Readable Files, published in accordance with the Transparency in Coverage final rule. The information contained in the files is accurate as of the “Last Updated” date and is subject to change at any time and without notice.
PLEASE NOTE: Due to the amount of information contained in these files, some may be as large as one Terabyte (TB) in size. Please ensure you have the required memory capacity, hardware, and software capabilities before attempting to download. The Machine Readable Files are formatted to allow researchers, regulators, and application developers to more easily access and analyze data.
Important Notices
 
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.