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 1-800-948-3253

2021 - 2022 Medical Benefit Information
 
Benefit Booklet View your entire benefit booklet containing information about all benefits offered to Team Members 2021-2022.
Copay Plan SBC This is the government-mandated summary of benefit coverage for the Medical Copay Plan.
$2,500 HSA Plan SBC This is the government-mandated summary of benefit coverage for the Medical $2,500 HSA Plan.
$5,500 HSA Plan SBC This is the government-mandated summary of benefit coverage for the Medical $5,500 HSA Plan.
Spouse/Domestic Partner Eligibility Verification This form is to be filled out if your spouse or domestic partner is enrolling in coverage.
Domestic Partner Affidavit Domestic Partners: Relationship Affidavit is to be filled out & submitted to HR.
Women’s Health and Cancer Rights Act This article will answer some of the common questions patients have about the WHCRA.
2020 - 2021 Medical Benefit Information
 
Benefit Booklet View your entire benefit booklet containing information about all benefits offered to Team Members 2020-2021.
Copay Plan SBC This is the government-mandated summary of benefit coverage for the Medical Copay Plan.
$2,500 HSA Plan SBC This is the government-mandated summary of benefit coverage for the Medical $2,500 HSA Plan.
$5,500 HSA Plan SBC This is the government-mandated summary of benefit coverage for the Medical $5,500 HSA Plan.
Spouse/Domestic Partner Eligibility Verification This form is to be filled out if your spouse or domestic partner is enrolling in coverage.
Domestic Partner Affidavit Domestic Partners: Relationship Affidavit is to be filled out & submitted to HR.
Women’s Health and Cancer Rights Act This article will answer some of the common questions patients have about the WHCRA.
HealthiestYou Telemedicine
 
Your healthcare just got a whole lot easier! With HealthiestYou you can connect with a doctor who can diagnose, treat, and prescribe over the phone 24/7/365.
Welcome to the better way to get healthy skin If you're having problems with your skin, HealthiestYou Dermatology can help.
A calm mind is a tap away HealthiestYou's licensed therapists are available seven days a week. Choose your therapist, pick a time that is convenient for you, and then talk to the therapist from the privacy of home or anywhere you feel comfortable.
Flexible Spending Account (FSA) Benefit Information
 
Flexible Spending Account (FSA) Calculator Worksheet Use this form to help you decide how much to set aside in your Health Care Reimbursement or Dependent Care FSA.
Eligible Expenses This document is an overview of eligible expenses.
Medical FSA Reimbursement Form Fill this form out when needing reimbursements for medical, dental, pharmacy or vision expenses. Your FSA Reimbursement Form can be submitted via email, fax, or through your personal online account.
Transportation FSA Reimbursement Form Fill this form out when needing reimbursements for transit & parking expenses. Your FSA Reimbursement Form can be submitted via email, fax, or through your personal online account.
FSA Direct Deposit Reimbursement Fill this form out to receive your reimbursement by direct deposit to your choice of bank account.
Pharmacy Benefit Information
 
CVS/Caremark Home Delivery Service Overview Provides on overview on the benefits of CVS/Caremark Home Delivery Service.
CVS/Caremark Home Delivery Service Form Provides information on how to use CVS/Caremark Home Delivery Service.
CVS/Caremark FAQ Frequently asked questions about CVS/Caremark Prescription Benefits and Home Delivery Service.
CVS/Caremark Home Delivery Service Form Use this form for mail order prescriptions from CVS/Caremark.
CVS/Caremark Home Delivery Service Form - Spanish Use this form for mail order prescription from CVS/Caremark.
CVS/Caremark Website Guide Provides information on how to use the CVS/Caremark website.
CVS/Caremark Mobile Application Provides information on how to use the CVS/Caremark mobile app.
Medicare Part D Notice This notice has information about your current prescription drug coverage and about your options under Medicare’s prescription drug coverage.
Generic Preventative Prescriptions High Deductible Health Plan (HDHP) - Health Savings Account (HSA) - Generics Only Preventive Therapy Drug List
Plan Documents
 
HIPAA Notification This notice details Life Time Fitness HIPAA compliance.
EZSPD An EZ to understand, short version of your Legal SPD.
Summary Plan Description (SPD) Provides information on how the medical plan operates, when employees are eligible for benefits, how services and benefits are calculated, when benefits become vested, when and in what form benefits are paid, how to file claims for benefits, and much more.
Summary Plan Description (FSA) Provides information on how the FSA operates, when employees are eligible for benefits, how services and benefits are calculated, when benefits become vested, when and in what form benefits are paid, how to file claims for benefits, and much more.
Summary Plan Description (Transportation) Provides information on how the Transportation Benefits Plan operates, when employees are eligible for benefits, how services and benefits are calculated, when benefits become vested, when and in what form benefits are paid, how to file claims for benefits, and much more.
Marketplace Notice Explains options for purchasing health coverage through the Insurance Marketplace.
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