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.
COVID-19 OTC Test Claim Reimbursement Form Use this form for your over-the-counter covid-19 test reimbursement
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
 
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 (HIPPA) 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.