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 1-844-281-5214

Medical Benefit Information
 
Benefit Overview Provides a high level overview of your HealthEZ medical benefits.
Copay Plan 1 SBC Provides an easy-to-understand summary about a health plan’s benefits and coverage.
Copay Plan 2 SBC Provides an easy-to-understand summary about a health plan’s benefits and coverage.
Copay Plan 3 SBC Provides an easy-to-understand summary about a health plan’s benefits and coverage.
Claim Reimbursement Form This form is to be filled out when needing reimbursements for medical, dental or pharmacy expenses.
Principal Dental & Vision Benefits
 
Dental Benefits Summary Provides a high level overview of your Principal Dental benefits.
Vision Benefits Summary Provides a high level overview of your Principal Vision benefits.
Dental & Vision Enrollment Form Principal Dental & Vision Enrollment Form
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