Form Library – License Office Benefits

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 844-302-7774

2025 Medical Benefit Information

Benefit Overview	Provides a high level overview of your HealthEZ medical benefits.
MEC Plan SBC	Provides an easy-to-understand summary about a health plan’s benefits and coverage.
2025 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.

HealthEZ Resources

Boost Your Baby	HealthEZ offers maternity support by providing education and resources to promote a healthy pregnancy through postpartum.
HealthEZ EZPay	Manage all your medical expenses in one simple spot with EZpay. Everything you need is at your fingertips in the free HealthEZ app.
How to Find Your HealthEZ EOB's & Statements	How to find your HealthEZ EOB's & Statements.
Understanding Your ID Card	Provides an easy-to-understand summary about how to read your HealthEZ ID card.

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
Pharmacy 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

Machine Readable File - PHCS Network

Machine Readable File – PHCS Network	Machine Readable Files, published in accordance with the Transparency in Coverage final rule. The information contained in the files is accurate as of the “Last Updated” date and is subject to change at any time and without notice.
Machine Readable File – Out of Network	Machine Readable Files, published in accordance with the Transparency in Coverage final rule. The information contained in the files is accurate as of the “Last Updated” date and is subject to change at any time and without notice.

Coordination of Benefits

Coordination of Benefits Form	Fill out the Coordination of Benefits form and submit to HealthEZ to document any secondary insurance coverage

Member Appeal Form

Member Appeal Form	Member Appeal Form

Preventive Care Guidelines

Preventive Care Guidelines	An ounce of prevention is worth a pound of cure. That’s why your health plan fully covers preventive care services. These services are defined by the U.S. Preventive Services Task Force and vary depending on age, sex, and pregnancy. All services classified as Grade A or B are covered at no cost to you.

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 Ac