Form Library

Everything you need in one place.

  1. 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 888-592-6267

Medical Benefit Information
 
Benefit Overview Provides a high level overview of your HealthEZ medical benefits.
Summary Plan Description (SPD) Provides information on how the medical plan operates, when employees are eligible for benefits, how benefits are paid, and much more.
Reference Based Pricing (RBP) Plan 1 SBC Provides an easy-to-understand summary about a health plan’s benefits and coverage.
Boost Your Baby Promoting healthy pregnancies and happy moms.
Livongo Program Learn more about the Livongo program's whole-person approach to chronic condition management.
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.
TrueRX 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
Teladoc Services
 
Teladoc Flyer Provides an overview on how to utilize your TelaDoc services
App Setup Provides step-by-step instructions on how to setup your TelaDoc account on the app
Web Registration Provides step-by-step instructions on how to setup your TelaDoc account on the app
Ancillary Benefits
 
Guardian Benefit Overview Provides a high level overview of your benefits through Guardian
Guardian Portal Link Use this link to access your benefits on Guardian anytime.
SHARx Program Flyer Provides an overview on SHARx services
EAP Employee Overview Provides and overview on your Employee Assistance Program, available through Uprise Health
KISxCard Flyer Provides an overview of the The KISx program.
KISxCard- Covered Procedure List Provides a summary of elective procedures available through the KISx program.
Highlight Health Flyer Provides an overview of Highlight Health.
Preventative Wellness Services
 
Preventative Wellness Services Provides information on your common preventative wellness services.
Important Notices
 
Precertification List Procedures that commonly require precertification
Your Rights and Protections Against Surprise Medical Bills When you get emergency care or get treated by an out-of-network provider at an in-network hospital or ambulatory surgical center, you are protected from surprise billing or balance billing.
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.
HealthEZ Privacy Policy A summary of key provisions of our Privacy Notice.