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 1-877-496-0754

Medical Benefit Information
 
Benefit Overview Provides a high level overview of your medical benefits.
Enrollment Form This form needs to be filled out if electing medical benefits.
EZSPD© An EZ to understand, short version of your Legal SPD.
HSA 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.
Organ Transplant Policy This form provides information about organ transplants.
Pharmacy Benefit Information
 
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.
Plan Documents
 
Summary Plan Description Provides detailed information about your medical benefits.
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.