Plan Forms

Forms, Notices, and more

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 844-281-5217

Questions about your benefits?

service@healthez.com

Register your myHealthEZ account

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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 Files
 
Machine Readable File – Aetna 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.
PLEASE NOTE: Due to the amount of information contained in these files, some may be as large as one Terabyte (TB) in size. Please ensure you have the required memory capacity, hardware, and software capabilities before attempting to download. The Machine Readable Files are formatted to allow researchers, regulators, and application developers to more easily access and analyze data.
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.
PLEASE NOTE: Due to the amount of information contained in these files, some may be as large as one Terabyte (TB) in size. Please ensure you have the required memory capacity, hardware, and software capabilities before attempting to download. The Machine Readable Files are formatted to allow researchers, regulators, and application developers to more easily access and analyze data.
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
Precertification List
 
Precertification List Common services that require precertification. For services not listed, contact the number at the top of this page for more information.
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
Surprise Billing and Balance Billing Protections Your Rights and Protections Against Surprise Medical Bills
CHIP Model Notice Premium Assistance under Medicaid and the Children’s Health Insurance Program
Modelo de aviso de CHIP Asistencia para el pago de primas bajo Medicaid y el Programa de Seguro Médico para Niños (CHIP)
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