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.
Claim Reimbursement Form This form is to be filled out when needing reimbursements for medical, dental or pharmacy expenses.
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
 
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